Saudi Board of Neurosurgery Curriculum - SCFHS

2020

Saudi Board of Neurosurgery Curriculum

SAUDI BOARD NEUROSURGERY CURRICULUM 1

CONTRIBUTORS

Prepared and updated by Curriculum Scientific Group

Dr. Abdulrazag Ajlan Dr. Khalid Bajunaid

Dr. Gmaan Alzahrani Dr. Abdulrahman Sabbagh

Dr. Mohammed Homod Dr. Ahmed Lary

Dr. Maher Hassonah Dr. Mohammed Bin-Mahfoodh

Supervision by

Dr. Sakra Balhareth Dr. Ali Alshehri

Reviewed and Approved by

Dr. Ali Hassan Assiri

2 SAUDI BOARD NEUROSURGERY CURRICULUM

COPYRIGHTS All rights reserved. © 2020 Saudi Commission for Health Specialties This material may not be reproduced, displayed, modified, or distributed without prior written permission from the copyright holder. No other use is permitted without prior written permission frim the Saudi Commission for Health Specialties. Any amendment to this document must be approved by the Scientific Committee and the Executive Council of the Saudi Commission for Health Specialties. It shall be considered effective from the date of its publication on the website, unless a different implementation date has been specified. For permission, contact the Saudi Commission for Health Specialties, Riyadh, Kingdom of Saudi Arabia. Correspondence: P.O. Box: 94656 Postal Code: 11614 Consolidated Communication Center: 920019393 International Contact Call: 00-966-114179900 Fax: 4800800 Extension: 1322 Website: www.scfhs.org.sa


TABLE OF CONTENTS SECTION 1: INTRODUCTION 5

Preamble 5 Definition 5 Vision 5 Mission 5 Educational goals and objectives 5 History 5 Scope of neurosurgical practice 6

Principal neurosurgical disciplines 6 Curriculum updates 6

Program framework 7 Program structure 7

SECTION 2: ACCEPTANCE AND ADMISSION TO THE PROGRAM 9

SECTION 3: OUTCOMES AND COMPETENCIES 10 Medical Expert 11 Communicator 12 Collaborator 12 Leader 13 Health Advocate 13 Scholar 14 Professional 14

SECTION 4: TEACHING AND LEARNING 16 Self-directed Learning 16 Core Education Program 16

Universal Topics 16 Core Specialty Topics 17

Practice-based learning 19 Common neurosurgical procedures 21 Technical skills 21

Courses and workshops 24

SECTION 5: ASSESSMENT 27 Formative Assessment 27

General Principles 27 Tools for Formative Assessment 27

Academic Activities Attendance (AAA) (Knowledge Parameter) 28 End of Year Promotion examination (Knowledge Parameter) 28 Blueprint Outlines 28 Blueprint Outlines 29

TABLE OF CONTENTS


In-Training End of Rotation reports (ITERs) (Attitude Parameter) 29 Surgical Logbook and DOPS (Skills Parameter) 30

Forms 30 Continuous holistic appraisals and assessments 30

Mid-rotation assessments and feedback 30 Resident portfolio 30

Summative Assessment 31 A. Part 1 Examination 31

Requirements to take the examination are as follows: 31 General Provisions 31 Examination Format 31 Suggested References 32 Blueprint Outlines 32 Example Questions 32

B. Final neurosurgery examination 35 Objectives 35 General Provisions 35 Examination Format 35 Passing Score 35 Suggested References 35 Blueprint Outlines 36 Example Questions 37

Final Objective Structured Clinical Examination (OSCE) 38 Exam Format 38 Final Clinical Exam Blueprint Outlines 38 Definitions 39

SECTION 6: CERTIFICATION OF TRAINING COMPLETION 40 Appendix 40

Appendix 1. Procedures List 41 Appendix 2. Annual Summary of Procedures Form 44 Appendix 3. In-Training Evaluation Report (ITER) 46 Appendix 4. Direct Observation of Procedural Skills (DOPS Assessment) 48 Appendix 5. Mini-Clinical Evaluation Exercise (MiniCEX) 50 Appendix 6. List of topics for Self-directed Learning 52

Part 1: Basic Science 52 Part 2: General Knowledge 58 Part 3: Neurosurgical Knowledge 68


SECTION 1: INTRODUCTION

Preamble

Definition Neurosurgery is a surgical specialty addressing a spectrum of disorders of the nervous system and meninges in adults and children that necessitate a neurosurgeon’s attention, intervention, or opinion. It mostly addresses highly critical conditions and demanding procedures.

Vision To provide the community with well-trained graduates who will be potential leaders in the field of neurosurgery, as reflected in our motto, “Bettering program outcomes to better patient outcomes.”

Mission To institute a progressive neurosurgical training program that is comparable to the world’s best such programs.

Educational goals and objectives Offer the highest quality of modern training and ensure that residents completing the training

have developed the required skills and competencies. Focus on training outcomes. The graduates must demonstrate their competencies in

essential neurosurgical domains so that they may readily transfer them into independent practice.

Accelerate learning and skill attainment through focused up-to-date teaching methods and frequent exposure to cases with balanced supervision and independence.

Involve the trainees in specialty-related community health projects and scholarly projects that will help shape their future practice.

History The recognized paucity of Saudi neurosurgeons and the rapid growth of the Saudi population have necessitated the establishment of a high-quality national program for training neurosurgeons. The first training program was a 1987 collaborative endeavor between King Faisal University in Dammam and the King Faisal Specialist Hospital and Research Center in Riyadh. This program was gradually replaced by the Saudi Neurosurgery Residency Training Program (SNRTP) that was established in 1995 under the authority of the Saudi Commission For Health Specialties (SCFHS). This program attracted an increasing number of trainees from Saudi Arabia and neighboring countries. This encouraged the establishment of an increasing number of high-quality training centers in Gulf countries. These centers are mainly located in major cities where several large hospitals can complement each other to fulfill training requirements.



Scope of neurosurgical practice Neurosurgeons treat diseases and conditions related to the nervous system at cranial, spinal, and peripheral nerve locations. As in other specialties, these diseases and conditions include several categories: Congenital and developmental disorders Degenerative disorders Trauma Neoplasm Vascular disorders Infection and inflammation Functional disorders

Principal neurosurgical disciplines Nervous system trauma and critical care:

Includes treatment and comprehensive management of head, spine, and peripheral nerve injuries. Head and spine injuries are a major cause of death and disability in children and young adults.

Pediatric neurosurgery:

Treats disorders of the developing nervous system, including hydrocephaly, brain malformations, cranial and spinal dysraphism, craniofacial anomalies, and intracranial masses.

Neuro-oncology:

Manages neoplasms of the brain, spinal cord, and meninges. Skull-base surgery:

Surgically accesses and manages neurosurgical diseases at or near the skull-base. Vascular neurosurgery:

Manages intracranial, spinal, and cervical vascular diseases with intravascular methods. The main conditions in this category are aneurysms, vascular malformations, carotid artery diseases, and cerebral ischemia.

Functional and epilepsy surgery

Manages epilepsy disorders, movement disorders, pain, and spasticity. Peripheral nerve surgery:

Manages trauma, entrapment syndromes, tumors, and other disorders of the peripheral nervous system.

Spinal surgery:

Treats traumatic, degenerative, and neoplastic conditions of the entire spine. This includes minimally invasive spinal procedures.

Above is a loose classification of existing neurosurgical subspecialties and not a complete list. Neurosurgery is an ever-expanding field with emerging new technologies and advancement.



Curriculum updates The SCFHS neurosurgery training program (SNRTP) is adopting a competency-centered training model within the confines of time-based training. Emphasizing competencies will improve training quality and outcomes, patient wellbeing, and the healthcare system in general. A structured, competency-based neurosurgical curriculum will better prepare residents for independent practice and protect patients from avoidable complications. The curriculum details the required basic neuroscientific and clinical neurosurgical knowledge and the methods of achieving objectives at different training levels. It will guide program directors and training staff in their efforts to provide residents with the necessary academic, clinical, technical, and professional training. A structured curriculum enables close monitoring of competency milestones to ensure that those promoted to higher training levels have attained the prerequisite competencies. Under the curriculum, the trainee bears gradually increasing responsibilities. The trainee is supervised by a staff neurosurgeon who grants him/her a certain degree of autonomy in preparation for independent practice after graduation. Our target neurosurgical competencies are best categorized by the Canadian Medical Education Directions for Specialists (CanMEDS) framework, which is internationally recognized in many training programs because of its comprehensiveness and relevance to specialists’ contemporary aspirations. The CanMEDS Framework defines 7 broad roles for physicians that lend themselves to refinement and improvement: Medical Expert Communicator Collaborator Leader Health Advocate Scholar Professional A team of leading neurosurgery educators was assembled to create and examine an SNRTP curriculum centered on these seven CanMEDS roles. The team defined competencies relevant to these roles and responsibilities, explored approaches for teaching and learning them, identified assessment mechanisms, and prepared a set of policies and procedures. Implementing a competency-centered curriculum requires incorporating the CanMEDS competencies into resident teaching, assessments/examinations, and accreditation standards. The curriculum should be readily available to all health stakeholders. Faculty training, through workshops, seminars, or CanMEDS educators, is essential to incorporating the CanMEDS roles throughout the residency training.

Program Framework

Program structure The program has a 6-year structure administratively divided into a 3-year junior level (R1-R3) and a 3-year senior level (R4-R6). The junior level primarily focuses on introducing the trainee



to the clinical neurosurgical specialty and informing him/her about general surgical principles and basic neuroscience. During the senior level, the trainee bears progressively increased neurosurgical and administrative responsibilities. Eighteen months of the 6-year program are spent in surgical and other medical specialties. This period is divided into 6 3-month rotations that are mostly completed during the junior level: General surgery Critical care Neurology Neuroradiology Neuropathology (can be done at senior level) An elective rotation (can be done during any training year except R6) The elective rotation is offered at any time during the training (except R6) to give the program some structural flexibility and to allow the residents to choose their own subject of interest in their chosen center. The residents will be exposed to new experiences to broaden their knowledge or skill in fields usually outside the core of neurosurgery. Several elective rotations are offered: Plastic surgery Otorhinolaryngology Neurophysiology Radiosurgery Neuro-ophthalmology Neuroanatomy Additional neurosurgery exposure Neurointervention The remaining 54 months are devoted to rotations within different neurosurgical disciplines: Pediatric neurosurgery (6 months) Spinal surgery (6 months) Functional surgery (3 months) Trauma (6 months) Cranial surgery, including neurovascular and neuro-oncological surgery (12 months) General neurosurgery including all of the above disciplines and peripheral nerve surgery

(21 months) During the general neurosurgery rotation, the resident has the opportunity to undergo additional training in 1 or more preferred fields. To facilitate training and the acquisition of skills and knowledge, the curriculum is stratified into 3-year junior and 3-year senior levels. Intense learning is an essential component of training at all levels. In the final year, the resident will acquire the title and status of Chief Resident, and he/she will hone his/her administrative and technical skills in preparation for independent practice after graduation. Training is conducted at institutions accredited for neurosurgical training by the SCFHS. A list of accredited centers is available from the SCFHS Accreditation Office.


SECTION 2: ACCEPTANCE AND ADMISSION TO THE PROGRAM Admission to the residency program is highly competitive. The applicants are evaluated against strict criteria to confirm their appropriateness before enrolment. For details about the admission requirements, please refer to the general bylaws of training and executive policies of acceptance and registration requirements at the SCFHS website (http://www.scfhs.org.sa/). Application requirements: 1. Bachelor’s degree in medicine and surgery (MBBS) from a Saudi University or equivalent

from recognized universities. 2. The applicant shall be medically fit according to the requirements of the profession applied

for. 3. The applicant shall undertake to pay full training, examination, and certification fees. 4. The applicant shall be registered within the Saudi Commission for Health Specialties at the

appropriate professional rank. 5. The applicant shall pass the Saudi Licensing examination of the profession, examination

held by the Commission, or equivalent. 6. The applicant shall follow the admission procedures in accordance with the implementation

rules approved by the Executive Council for Education and Training in a timely manner.


SECTION 3: OUTCOMES AND COMPETENCIES

Introduction to learning outcomes and competency-based education Training should be guided by well-defined learning objectives that are driven by targeted learning outcomes of a particular program to serve specific specialty needs. Learning outcomes are supposed to reflect the professional competencies that are aimed for trainees to be entrusted in upon graduation. This will ensure that graduates will meet the expected demands of the healthcare system in relation to their particular specialty. Competency-based education (CBE) is an approach of adult-learning that is based on achieving pre-defined, fine-grained, and well-paced learning objectives that are driven by complex professional competencies. Professional competencies related to healthcare are usually complex and entertain a mixture of multiple learning domains (knowledge, skills, and attitude). CBE is expected to change the traditional way of postgraduate education. For instance, though time of training is a precious resource, it should not be looked to as a proxy for competence (e.g. time of rotation in certain hospital areas is not the primary marker of competence). Furthermore, CBE emphasizes the critical role of informed judgment of learners’ competency progress, which is based on a staged and formative assessment that is driven by multiple workplace-based observations. Several CBE models have been developed for postgraduate education in healthcare (for example, CanMEDs by the Royal College of Physicians and Surgeons of Canada (RCPSC), the CBME-Competency model by the Accreditation Council for Graduate Medical Education (ACGME), Tomorrow’s Doctors in the UK, and multiple others). The following are concepts to enhance the implementation of CBE in this curriculum: Competency: Competency is a cognitive construct assessing the potential to perform

efficiently in a given situation based on the standards of the profession. Professional roles (e.g. expert, advocate, communicator, leader, scholar, collaborator, and professional) are used to define competency-role in order to make it identifiable for learning and assessment.

Milestones: Milestones are points along the developmental journey throughout the competency continuum. Trainees throughout their learning journey, from junior and throughout senior levels, will be assisted to transform from being novice/supervised into master/unsupervised practitioners. This should not undermine the role of supervisory/regulatory bodies toward malpractice of independent practitioners. Milestones are expected to enhance the learning process by pacing the training/assessment to match the developmental level of trainees (junior vs. senior).

Learning domains: Whenever possible, efforts should be directed to annotate the learning outcomes with the corresponding domain (K=Knowledge, S=Skills, and A=Attitude). In general, it is advisable to design learning outcomes at the mid-level (i.e. neither too broad nor too specific). For example, “Demonstrate competency in taking a focused pediatrics history and performing a complete and appropriate physical examination (S).” One might have more than one annotation for a given learning outcome.

Content-area categorization: It is advisable to categorize the learning outcomes by the broad content area related to the practice of the profession. For example, in pediatrics some of the content areas are: growth, nutrition, development, adolescent health issues, prevention and healthy lifestyle, diagnosis, and management of childhood diseases.



Mapping of Milestones The SNRTP curriculum is centered on these seven CanMEDS roles. MEDICAL EXPERT COMMUNICATOR COLLABORATOR LEADER HEALTH ADVOCATE SCHOLAR PROFESSIONAL

Medical Expert During the Junior years, the trainee should gain the medical expertise to be able to:

1. apply knowledge of the basic and clinical sciences relevant to surgical neurology. 2. obtain a detailed and accurate medical history 3. conduct a thorough and accurate general and neurological physical examination 4. localize the precise anatomical sites of neurological disorders based on clinical findings

and investigations 5. perform a differential diagnosis by evaluating symptoms and signs 6. outline a medical and surgical management plan 7. manage common and important perioperative problems 8. demonstrate the technical skills necessary for neurosurgical procedures (refer to table

under Technical skills) 9. gradually improve clinical decision-making skills so that he/she can function

independently at senior level 10. thoroughly understand the use and interpretation of ancillary diagnostic aids for

neurological diseases During the Senior years, the trainee should gain the medical expertise to be able to:

1. help junior residents and other health professionals understand the basic science pertinent to particular neurosurgical cases

2. demonstrate the technical skills necessary for neurosurgical procedures (see table at the end of this section)

3. write a concise but accurate pre-operative note that includes the following Primary diagnosis Concurrent diagnoses Surgical goals Expected course and risks Perioperative monitoring Management plans 4. demonstrate the technical skills necessary for neurosurgical procedures (refer to table

under Technical skills) 5. correctly choose and use surgical instruments 6. properly position patients for surgery 7. achieve optimal surgical exposure with minimal healthy tissue disruption, blood loss,

cosmetic damage, and risk of bacterial contamination 8. efficiently complete surgeries 9. properly close surgical wounds with minimal blood loss and infection risk and with

optimal chances for wound healing and functional recovery



Communicator Junior years Demonstrates proficient verbal and written communication with patients and their relatives:

1. Can explain neurological diseases 2. Can guide patients and their families to sources of reliable information about

neurosurgical conditions and coping methods 3. Can seek and understand feedback from patients and their families regarding care given

by oneself and one’s team 4. Can track outcomes of cases in which one has had significant involvement

Demonstrates proficiency in dictating and charting the following:

1. Histories 2. Physical examinations 3. Consultations 4. Progress notes 5. Discharge summaries 5. Preoperative notes 7. Operative notes

Senior years Demonstrates proficiency in presenting clinical and investigative information at teaching

rounds and scientific conferences and can interactively engage the audience and accurately evaluate learning results

Can list management options and present information needed for informed consent for surgery while confirming that the patient or substitute decision-maker has adequate recall and understanding of that information

Accurately informs and advises family or other significant associates of procedure completion, expected outcomes and risks, and plans for the early postoperative phase

Collaborator Junior years Can effectively participate in interdisciplinary meetings and demonstrate:

1. Professional behavior 2. Respect for healthcare team members’ opinions 3. Comprehension of others’ in-depth expertise 4. Contribution to decision-making

Demonstrates awareness of his/her limitations and those of other healthcare team members

by: 1. Not anticipating and declining performance of surgery if he/she is unfamiliar with the

patient and/or the procedure Can interact with physicians and surgeons from other specialties

1. Understands collective and individual responsibilities in multi-specialty surgeries 2. Recognizes and respects boundaries between specialties



Senior years Can perform surgical procedures accurately and efficiently and demonstrate the following:

1. Organizes tasks so that the surgical team can perform them efficiently and safely 2. Anticipates next steps and communicates with team members to avoid unnecessary

confusion, stress, and delay 3. Uses proper technical lexicon in communicating with surgical nurses

Can help others and himself/herself to become fully aware of each other’s strengths and weaknesses in a timely and professional manner

Leader Junior years Can properly use appropriate laboratory aids to document and substantiate the clinical

diagnosis Demonstrates practical administrative skills such as:

1. arranging meetings 2. delegating tasks 3. chairing meetings 4. setting schedules 5. resolving problems with self-control and fairness

Senior years Appropriately delegates clinical and scholarly tasks to residents and clerks and evaluates

their results Obtains informed consent, appropriately discusses the planned surgical intervention with a

patient’s relevant associates, and demonstrates the ability to prepare for the surgical procedure by 1. scheduling the procedure based on its urgency and duration 2. requisitioning the appropriate equipment 3. assembling a team capable of the procedure 4. accurately noting potential teaching and learning opportunities and planning for their

utilization

Health Advocate Junior years In appropriate circumstances, acts as a health advocate for the patient to facilitate optimal

outcomes Demonstrates awareness of efficacious prophylactic measures for various at-risk patient

groups (e.g., educational interventions) Senior years To be proactive when needed to overcome systemic problems such as access to healthcare

resources for diagnosis and treatment Understands the determinants of health as they apply to neurosurgical patients and seeks to

provide appropriate resources and opportunities for patient health and autonomy



Scholar Junior years Clinical issues: identifies clinical issues that he/she does not fully understand and does the

following: 1. Formulates a clinical question 2. Identifies his/her own knowledge and its limitations 3. Develops a plan for appropriate research 4. Assimilates and analyzes the material available 5. Consults other physicians and allied health care personnel as needed 6. Proposes a solution to the clinical question 7. Implements the solution 8. Evaluates the solution’s efficacy 9. Formulates relevant new clinical questions

Research issues: demonstrates ability to

1. generate a research question 2. review relevant literature 3. assimilate the literature 4. identify and collaborate with appropriate personnel 5. write a research proposal 6. conduct the research 7. disseminate the results by presenting at conferences, writing a paper for publication,

and identifying future research possibilities Educational issues: demonstrates ability to

1. understand the principles of self-directed learning 2. teach clinical clerks and undergraduates the various clinical and surgical aspects of

neurosurgery 3. impart appropriate clinical information to allied health personnel 4. review textbooks, papers, and other publications prior to surgery and be comfortable

with the surgical approach prior to the operation 5. prepare for neuroscience rounds and neurosurgical seminars despite busy schedule 6. study and use hardcopy and electronic sources to gather information relating to

observations in the emergency room, clinics, and neurosurgical wards Senior years Accurately, consistently, and conspicuously incorporates evidence-based research and

guidelines into treatment decisions and discussions, particularly noting points of controversy and progress

Supports, attends, and often organizes educational sessions for the neurosurgical team

Professional Junior years Professionally interacts with patients, relatives, his/her peers, and other healthcare

personnel Respects the opinions of others Provides care in an honorable and ethical manner Can evaluate his/her knowledge and abilities and their limitations



Addresses his/her limitations by asking for help from colleagues when he/she is

uncomfortable with a clinical situation Demonstrates a keen sense of responsibility and compassion Senior years Demonstrates appropriate continuing patient care by completing and documenting frequent

postoperative visits to ensure that patients’ needs for comfort, safety, information, and optimal outcomes are met

Helps guide junior residents in all aspects of their learning and training Evaluates himself/herself and fellow health professionals in an accurate, effective,

professional, and timely manner

Continuum of Learning This includes learning that should take place in each key stage of progression within the specialty. Trainees are reminded of life-long Continuous Professional Development (CPD). Trainees should keep in mind the necessity of CPD for every healthcare provider in order to meet the demands of their vital profession. The following table states how the role is progressively expected to develop throughout junior, senior, and consultant levels of practice.

Postgraduate Undergraduate

R 1-3 (Junior Level) R 4-6 (Senior Level)

Continuous Professional Development

Non-practicing Dependent/supervised practice

Dependent/supervised practice

Independent practice/provide

supervision Pre-entrustable Approaching

entrustable Approaching entrustable

entrustable

Obtain basic health science

and foundational level to core

discipline knowledge

Obtain fundamental knowledge related to core clinical problems

of the specialty

Apply knowledge to provide appropriate

clinical care related to core clinical problems

of the specialty

Acquire advanced and up-to-date

knowledge related to core clinical problems of the

specialty Internship to the

practice of discipline

Apply clinical skills such as physical examination and

practical procedures related to the core

presenting problems and procedures of the

specialty

Analyze and interpret the findings from clinical skills to

develop appropriate differential diagnoses and management plan

for the patient

Compare and evaluate

challenging, contradictory findings and

develop expanded differential

diagnoses and management plan


SECTION 4: TEACHING AND LEARNING Learning is achieved through the following formats: 1. Self-directed learning: This is the principal form of learning in which the trainee,

independently or with assistance, takes initiative and responsibility for identifying his/her learning needs, formulating learning goals, choosing and implementing appropriate learning strategies, and evaluating learning outcomes.

2. Core Education Program: A formal education and training program that includes a. universal topics b. core specialty topics (e.g., city-wide 3 hours per week of academic activity) c. self-selected topics d. courses, workshops, and simulations e. professional development topics f. research skills: the trainee is encouraged to participate in research projects anytime

during their training 3. Practice-based learning that includes

a. clinical case-based learning b. morning reports and discussion c. case presentations and grand rounds d. morbidity and mortality reviews e. journal clubs and evidence-based neurosurgery f. neuroradiology and neuropathology sessions g. multidisciplinary case discussions (e.g., tumor board)

The weekly academic activities vary between training sites. Each week features 6-12 hours of education including 3 hours of formal teaching. 4. Technical skills and procedural milestones

Self-directed Learning Part of the trainee education should be performed inside and outside the formal channel. By the end of the training period the following topics should covered. The three self-directed learning domains are Basic science, General Knowledge, and Neurosurgical Knowledge (for listing of topics refer to Appendix 6).

Core Education Program

Universal Topics These are high-value, interdisciplinary topics of utmost importance to the trainee. They are centrally delivered by the SCFHS through an e-learning portal. The duration of each topic is 1.5 hours, and it is followed by an online formative assessment. After completion of all topics, there is a combined summative multiple-choice test for further details about each module objectives and content (refer to e-learning portal). All 16 topics should be completed within the 3-year junior level of training. These topics are:

SECTION 4: TEACHING AND LEARNING


R1 topics 1. Hospital-acquired infections (module 1) 2. Sepsis, systemic inflammatory response syndrome, and disseminated intravascular

coagulation (module 1) 3. Blood transfusion (module 1) 4. Side effects of chemotherapy and radiation therapy (module 2) 5. Managing hypotension and hypertension (module 4) 6. Fluids management for inpatients (module 5) 7. Managing electrolytes imbalances (module 5) R2 topics 1. Preoperative assessment (module 5) 2. Postoperative assessment (module 5) 3. Managing acute pain (module 5) 4. Managing chronic pain (module 5) R3 topics 1. Occupational hazards for healthcare workers (module 7) 2. Patient advocacy (module 7) 3. Ethical issues: transplantation/organ harvesting and withdrawal of care (module 7) 4. Ethical issues: treatment refusal and patient autonomy (module 7) 5. Role of doctors in death and dying (module 7)

Core Specialty Topics Knowledge Each week involves a city-wide 3-hour formal interactive supervised teaching activity covering topics including neurosurgical anatomy, pathophysiology, clinical neurosurgery, and common neurosurgical techniques. They are distributed over the following subjects to cover the main neurosurgical subspecialties: 1. Spinal surgery 2. Functional surgery 3. Neurovascular surgery 4. Neuro-oncology 5. Pediatric neurosurgery 6. General neurosurgery The trainee is relieved of clinical duties for the 3 hours of the weekly session. The trainees take the lead in preparing and presenting these sessions, though staff neurosurgeons provide supervision and contribute ideas. The sessions consist of trainees giving short didactic lectures and case presentations to each other under the moderation of staff neurosurgeons. Each subject is reviewed for 3 months. Three subject reviews occur in a year, and all 6 form a cycle that is repeated every 2 years. The first year covers spinal, functional, and neurovascular surgery while the second-year covers neuro-oncology, pediatrics, and general neurosurgery. This 2-year cycle is important for the end of year promotion exam (please refer to the corresponding appropriate section blueprint).



Reviewed subject Learning outcomes Spinal surgery

Understand and review the anatomy of different spinal regions with an emphasis on junctional zones

Recognize the basic biomechanics of different spinal regions and how they relate to spinal anatomy

Review the pathogeneses of different spinal pathologies and how they impact treatment

Understand basic spinal cord anatomy and its blood supply, pathological conditions, and related clinical presentations

Understand the pathology, assessment, and modern treatment of spinal cord injuries

Recognize critical signs and know how to respond to various spinal emergencies

Discuss various spinal pathology cases and demonstrate the ability to choose appropriate treatment options

Understand the scientific literature and the latest seminal articles Functional surgery

Understand the principles of stereotactic surgery and the basic science of basal ganglia and motor circuits

Understand surgeries for movement disorders Understand surgeries for epilepsy Understand neurosurgeries for pain Understand other current applications of functional neurosurgery

Neurovascular surgery

Understand the neurovascular anatomy of the brain and spinal cord Understand the pathophysiology of various neurovascular problems

affecting the brain and spinal cord Can diagnose and manage all neurovascular lesions Understand various surgical approaches and techniques for

vascular lesions Selects appropriate techniques for managing these lesions,

including neuro intervention procedures and radiosurgery Neuro-oncology

Understand the basic pathological descriptions of intracranial tumors affecting the brain, skull base, spinal cord, and peripheral nerves

Understand the latest molecular genetics research into brain neoplasms

Understand the clinical presentations of patients with brain tumors and understand different assessment and treatment options

Be able to plan and execute standard and complex surgical approaches

Clearly understand intracranial brain cysts, non-neoplastic lesions, and other benign pathologies



Pediatric neurosurgery

Understand the importance of minimal blood loss and proper technique to avoid excessive blood loss

Understand the basic pathological descriptions of common congenital anomalies in spinal dysraphysim, hydrocephalus, and encephalocele

Understand the principle mechanics, genetic basis, and management of craniosynostosis and syndromic craniosynostosis

Understand the genetics of infantile and pediatric brain tumor Understand the clinical presentation of phakomatosis or

neurocutaneous tumor genetics and management of different types General neurosurgery

Understand the perioperative management of neurosurgical patients and how to avoid complications

Understand positions and approaches for neurosurgical procedures Is familiar with the neurosurgical armamentarium Understand the pathophysiology, types, critical care, and timely

surgical management of head trauma Understand the indications and outcomes for brain injury

rehabilitation Understand the pathophysiology, diagnosis, and management of

peripheral nerve entrapments, injuries, and neoplasms Can recognize, diagnose, and manage various nervous system

pathogens, with emphasis on immunocompromised cases and common infections

Practice-based learning Practice-based learning essentially involves orienting the resident to decision-making regarding fact collection on actual medical problems. In other words, residents confront contextualized, counter-intuitive problems and strive to find meaningful solutions.

Activity Objectives Trainees will learn to do the following:

Clinical case-based learning

Generate explanatory hypotheses for patients’ problems that refer to anatomical locations, pathophysiological processes, and etiological mechanisms

Conduct a focused inquiry to obtain the information necessary to confirm or reject a hypothesis

Analyze clinical data based on hypotheses concerning the basic mechanisms responsible for symptoms, signs, and laboratory findings

Synthesize acquired data into an organized, developing picture of the patient’s problem

Design an appropriate intervention and management plan Morning reports and discussion

Educate all attending residents, monitor patient care, and review management decisions and their outcomes

Develop competence through short scientific and informative presentations on all admitted patients

Develop confidence in systematically presenting complex cases Learn to appropriately perform differential diagnoses and develop

proper management plans



Case presentations and grand rounds

Present a comprehensive history and physical examination with details pertinent to the patient’s problem

Formulate a list of all problems identified in the history and physical examination

Develop a proper differential diagnosis for each problem Formulate a diagnosis and treatment plan for each case Present a follow-up patient’s case in a focused, problem-based

manner that includes pertinent new findings and diagnostic and treatment plans

Demonstrate a commitment to improving case presentation skills by regularly seeking feedback

Morbidity and mortality reviews

Learn from complications and errors Modify behavior and judgment based on previous experiences Avoid repetition of errors leading to complications Identify areas for improvement for clinicians involved in case

management Journal clubs and evidence-based neurosurgery meetings

Systematically appraise and assimilate scientific evidence from journal articles

Apply knowledge of study designs and statistical methods to appraise clinical studies and other sources of information on diagnostic and therapeutic effectiveness

Cite specific articles in future grand rounds or morning rounds presentations or in charts of patients with relevant conditions

Facilitate the education of other residents Synthesize information from articles with knowledge of relevant

clinical and basic sciences to achieve an analytical and investigative approach to patient care

Encourage all group members to participate, especially those who have difficulty doing so

Neuroradiology and neuropathology sessions

Discuss cases of interest, describe radiological findings, and elaborate on the differential diagnosis

Review pathological slides and discuss the findings with neuropathologists

Multidisciplinary case discussion (e.g., tumor board)

Participate in multidisciplinary discussions of new diagnoses and review cases of cancer within an appropriate timeframe to facilitate effective treatment planning

Use all available information and evidence to determine the most appropriate treatment plan for each patient

Participate in educational opportunities for team members and trainees



Skills

Common neurosurgical procedures A full list of neurosurgical procedures would be too extensive to present here, but a list of major groupings can be presented: Procedures related to head trauma (e.g., burr holes, craniotomies, and craniectomies) Cerebrospinal fluid (CSF) diversions Closure and repair of spina bifida disorders Craniotomies for intracranial masses Craniotomies and craniectomies for vascular disorders Transsphenoidal and skull base approaches Endoscopic procedures Discectomies and decompressive laminectomies Spinal instrumentations and fusions for degenerative diseases and trauma Epilepsy procedures Movement disorder procedures Peripheral nerve procedures

Technical skills Independent component (without

step-by-step supervision) Assisting/supervised component (step-by-step supervision)

R1 • Sterile technique • Professional behavior in operating

team • Postoperative patient transfer • Urinary catheter insertion • Wound dressing o Cranial wounds o Spinal wounds o Limb wounds

General • Lumbar puncture • Ventriculostomy and lumbar drain • Preoperative skin preparation and draping • Preoperative patient registration in the

neuronavigation system • Understanding of surgical equipment o Microscope o Ultrasonic aspirator o Craniotome/high-speed drill

• Craniotomy closure (bone to skin) R2 • All R1 supervised activities

• Accurately listing goals and risks of surgical procedures

• Accurately naming surgical instruments

• Preoperative patient registration into the neuronavigation system

General • Operating hemostatic tools • Surgical exposure (skin to dura) • Decompressive craniectomy Trauma • Elevation of depressed skull fractures • Surgical management of extra-axial

hematomas Tumor • Positioning for supratentorial craniotomies • Positioning for transsphenoidal surgery Pediatrics • Ommaya reservoir placement • Ventricular tap



Spinal

• Positioning for surgery • Posterior approach exposure (skin to

bone) PNS • Nerve/muscle biopsy

R3 • All R2 supervised activities • Accurately estimating procedure

duration and expected blood loss

General • Bone flap re-implantation/cranioplasty • Opening dura Trauma • Surgical management of complex skull

fractures • Surgical management of intra-axial

hematomas Tumor • Intracranial tumor resection Pediatrics • Ventriculoperitoneal shunts Functional and epilepsy • Stereotactic brain lesion biopsy Spinal • Skeletal traction application • Closure of spinal dura • Posterior approach exposure (skin to

dura) PNS • Carpal tunnel syndrome

R4 • All R3 supervised activities Tumor • Craniectomy for posterior fossa tumors • Transsphenoidal resection of pituitary

adenoma Pediatrics • Simple craniosynostosis Functional and epilepsy • Stereotactic calculation of target

coordinates • Vagus nerve stimulation • Frontal lobectomy Spinal • Chiari malformation decompression • Anterior approach exposure (skin to bone) • Applying lumbar pedicle screws PNS • Surgical management of entrapment

neuropathy • Primary nerve anastomosis



R5 • All R4 supervised activities Tumor

• Craniotomy for complex tumors Pediatrics • Complex craniosynostosis repair • Repair of myelomeningoceles Functional and epilepsy • Stereotactic electrode placement • Anterior temporal lobectomy Vascular • Surgical clipping of simple aneurysms Spinal • Anterior cervical discectomy • Spinal tumor removal • Applying thoracic and subaxial cervical

screws R6 • All R5 supervised activities Tumor

• Craniotomies for complex skull base tumors

Pediatrics • Neuro endoscopy in the cranial cavity Functional and epilepsy • Lesionectomy • Corpus callosotomy • Awake craniotomy Vascular • Surgical management of complex

aneurysms • Resection of supratentorial vascular

malformations Spinal • Applying axial cervical screws • Advanced spine instrumentation PNS • Brachial plexus surgery • Resection of peripheral nerve tumors

To reach the milestones discussed below, the trainee is expected to perform different procedures at various training levels, though the expectations are subject to personalized assessments and evaluations of the residents’ abilities. Please refer to the table in Appendix 1. As indicated in this table, the minimum number of cases expected per year is as follows (these numbers may vary by +/-10% due to the different rotations performed by trainees each year): R1 Level: 100 cases/year R2 Level: 110 cases/year R3 Level: 120 cases/year R4 Level: 140 cases/year R5 Level: 150 cases/year R6 Level: 100 cases/year



Attitude The residents will be monitored during his/her daily activities for attitude and behavior skills. A multisource feedback will be used to assess the progression and to correct the areas for improvement. The behavior skills that are most required in neurosurgery residents before graduation are mainly good interpersonal and communication skills. The residents are expected to act and participate in the patients’ care according to the expected level of responsibility and to communicate appropriately with the medical personnel and the patients and their families. The residents are expected to be responsible for their patient and demonstrate their responsibility in preoperative, intraoperative, and postoperative management periods with a high level of confidentiality.

Courses and workshops This is a list of example courses and workshops that are currently running, and residents are recommended to take them. It is far from exhaustive. New courses, workshops, and simulation centers are expected to emerge in the near future.

Course name Principles SCFHS resident training level

Neurosurgery Boot Camp

Intensive 2-day course for the upcoming neurosurgical trainees to expose them to the basic knowledge and skills to facilitate the beginning of their residency.

Junior level

Basics of Drilling

High-speed drilling is a basic neurosurgical skill. This hands-on course teaches basic skills and techniques for high-speed drilling at the skull and skull base. It starts with simple “dry” exercises to familiarize trainees with different burr types for different indications.

Junior level

Basic Neurosurgical Approaches

This course covers basic neurosurgical techniques and clinical knowledge necessary for residents to advance in neurosurgery. A key feature is the practical skills training on cadaveric material. It provides instruction in:

• Frontotemporal craniotomies • Bifrontal craniotomies • Parasagittal craniotomies • Posterior fossa craniotomies

Junior level

Basic Operative Surgical Skills

(BOSS)

This course introduces trainees to safe surgical practice within a controlled workshop environment. It aims to teach, assess, and certify the ability to use safe, sound surgical techniques that are common to all forms of surgery. The course covers:

• Safe operating practices, gowning, and gloving • Handling of surgical instruments • Suturing techniques • Safe surgical knots • Tissue handing and wound management

Junior level



Advanced

Trauma Life Support (ATLS)

ATLS trains medical providers in acute trauma management, with an emphasis on treating the greatest threat to life first. It stresses that the lack of a definitive diagnosis and detailed history should not delay the application of indicated treatments for life-threatening injuries, with the most time-critical interventions performed first.

Junior level

Neurolife (Neurocritical Care Course)

The neurocritical course program focuses on the latest evidence-based management of all aspects of neurocritical care. This 1-day course includes a combination of didactic, case-based, and evidence-based guideline review, as well as interactive case discussion workshops and multimodal monitoring case review. It is usually held in collaboration among the Saudi Association of Neurological Surgery Society (SANS) and the Neurocritical Care Chapter of the Saudi Critical Care Society (SCCS).

Junior and Senior levels

Microsurgery Course

This course covers the use of operating microscopes, micro instruments, and micro sutures. Participants are trained in vessel dissection, various microsurgical techniques, arterial and venous end-to-end and end-to-side anastomosis, and vascular graft preparation and placement.

Junior level

Skull Base Approaches

(Open Advance and Endoscopic

Advanced)

This workshop provides neurosurgeons, fellows, and residents the opportunity to enhance their own skills in a variety of surgical and endoscopic skull base approaches. The participants:

• review and perform surgical approaches to the anterior, lateral, and posterior skull base on cadaveric specimens, under the direction of world-class faculty

• perform endoscopic approaches to the anterior skull base

• discuss the surgical techniques and complexity of the various surgical skull base approaches, view surgical videos, and interact with world-renowned experts in the field

• discuss complication avoidance

Senior level



Spine Update

This course covers degenerative spinal diseases, spinal trauma, spinal cord injuries, and spinal tumors. The latest technologies, including motion preservation, and minimally invasive spinal surgery are addressed in full reviews and scientific debates throughout the conference. It includes a 1-day hands-on cadaveric workshop that covers common surgical approaches to the cervical, thoracolumbar, and lumbar spine including lumbar discectomy. The workshop uses Thiel-embalmed human cadavers to provide a realistic operating room experience. Presentations are kept to a minimum so that most of the day is spent practicing operative skills.


Arab Spine Course Diploma

This course aims to establish Arab education standards, both for spine specialists in training and as part of continuous medical education that utilizes research and advocacy to promote the highest quality of treatment and prevention-based spinal care.

Senior level

Peripheral Nerve Course

This course focuses on peripheral nerve surgical anatomy. The lectures provide an overview of recent advances in nerve injury, healing, repair, and rehabilitation. Throughout the workshop, participants can refine their surgical skills in nerve repair and nerve grafting/transfers.


Virtual Reality (VR)

Neurosurgical Skill Training

Course

The use of currently available neurosurgical skill training VR simulation technologies is expected to help trainees exercise some basic and intermediate skills on the VR platform in a safe environment. The equipment is available to trainees during courses or independently in 2 institutions at this point. King Fahad Medical City and King Abdelaziz University Hospital (NeuroVR® and ImmersiveTouch®).


Chicago Review Course

Chicago, USA

An intensified 1-week course with 10-hour daily lectures in all aspects of neurosurgery neuroanatomy, neurophysiology, and pathology, usually attended by neurosurgery residents before the final exam in North America. This is a intensive review course more than an education.

Senior level


SECTION 5: ASSESSMENT

Formative Assessment

General Principles Trainees, as adult learners, should strive for feedback throughout their journey of competency from “novice” to “mastery” levels. Formative assessment (also referred to as continuous assessment) is the component of assessment that is distributed throughout the academic year, aiming primarily to provide trainees with effective feedback. Input from the overall formative assessment tools will be utilized at the end of the year to make the decision of promoting each individual trainee from current to subsequent training level. Formative assessment will be defined based on the scientific council recommendations (usually updated and announced for each individual program at the start of the academic year). According to the executive policy on continuous assessment (available online: www.scfhs.org), formative assessment will have the following features: a. Multisource: minimum four tools. b. Comprehensive: covering all learning domains (knowledge, skills, and attitude). c. Relevant: focusing on workplace-based observations. d. Competency-milestone oriented: reflecting trainees’ expected competencies that match their

developmental level. Trainees should play an active role in seeking feedback during their training. Also, trainers are expected to provide timely and formative assessment. SCFHS will provide an e-portfolio system to enhance communication and analysis of data arising from formative assessment.

Tools for Formative Assessment Formative assessment complies with the updated general policy of SCFHS that includes promotion criteria and selection of tools and is divided into knowledge, skills, and attitudes. Trainees and trainers are advised to follow any adjustments by the scientific council. The following table summarizes the assessment tool that was approved at the time of this curriculum approval:

Level of training (year)

Knowledge Skills Attitude

1-5 1- Percentage of attendance of the weekly half-day academic activities. 2- End of year promotion examination 3- SOE

Logbook and DOPS

In-Training End of Rotation reports (ITERs)

6 1- SOE Logbook and DOPS

1- In-Training End of Rotation reports (ITERs)

2- MiniCEX



Academic Activities Attendance (AAA) (Knowledge Parameter) Attendance of the obligatory weekly academic activities organized by SCFHS is counted each session. The percentage of attendance will indicate the AAA mark. The activities are held and broadcasted every Tuesday from 1:00-4:00pm across all programs throughout the Gulf. The activities are organized by the regional program directors. Attendance of 70% or more of this weekly activity is required to pass this parameter. Two exemptions: 1- Sixth year residents are exempt from this activity but allowed to attend if they want and

freed from clinical obligations only if they are attending. Sixth year residents will be given 100% in this parameter.

2- Fifth year residents should attend 50% or more to get a borderline pass.

End of Year Promotion examination (Knowledge Parameter) This annual examination is prepared by the training committee, with 80% of the examination covering the topics given during the weekly academic activities in that year (please refer to the core specialty topics section above). The blueprint below alternates according to the academic year cycle.

Blueprint Outlines The content of the following table is for demonstration only; please refer to the most updated version published on the SCFHS website. End-of-year written neurosurgery examination (Cycle 1: Spine, functional, and neurovascular) blueprint

TOPICS % Clinical and operative neurosurgery Neuro-oncology 3 Pediatric neurosurgery 3 Spinal surgery 15 Cranial trauma 4 Neurovascular surgery 15 Infections 3 Functional neurosurgery 15 Peripheral nerve surgery 3 General neurosurgical principles, approaches, and adjuvant therapies 15 Basic neurosciences and practice-related topics Neurosurgical anatomy 10 Neuropathology, molecular biology, neuroradiology, and diagnostic approaches 5

Pathophysiology, neurophysiology, and neurology 3 Neurocritical and general care, pharmacology, and neuroanesthesia 3 CanMEDS roles and research skills 3 Total 100%

Note: Blueprint distributions of the examination may differ up to +/-3% in each category.



Blueprint Outlines The content of the following table is for demonstration only, please refer to the most updated version published on the SCFHS website. End-of-year written neurosurgery examination (Cycle 2: Neuro-oncology, pediatrics, and general neurosurgery) blueprint

TOPICS % Clinical and operative neurosurgery Neuro-oncology 15 Pediatric neurosurgery 15 Spinal surgery 3 Cranial trauma 10 Neurovascular surgery 3 Infections 7 Functional neurosurgery 3 Peripheral nerve surgery 10 General neurosurgical principles, approaches, and adjuvant therapies 10 Basic neurosciences and practice-related topics Neurosurgical anatomy 10 Neuropathology, molecular biology, neuroradiology, and diagnostic approaches

5

Pathophysiology, neurophysiology, and neurology 3 Neurocritical and general care, pharmacology, and neuroanesthesia 3 CanMEDS roles and research skills 3 Other Total 100%


In-Training End of Rotation reports (ITERs) (Attitude Parameter) Formerly this was referred to as the end of rotation evaluation. Typically, this evaluation is done 4 times per year concluding each 3-month rotation. In case of shorter rotations, the ITERs would be given for that period and averaged with the rest of the ITERs of the same 3-month period according to its weight. It is crucial that marking per each item in the ITERs and the overall marking truly reflects the resident’s performance. According to this: 1. a resident who clearly performs at level appropriate to their year of training should “Clearly

Pass” the rotation if they score 70% or above. 2. a borderline pass resident should be assigned a mark between 60 to 69.4%. 3. a borderline fail resident should be assigned a mark between 50 to 59.4%. 4. a clear failure is a mark below 50%. 5. Please refer to the guidelines outlined in the SCFHS executive policy of continuous

assessment.



Structured Oral Exam (SOE) This SOE is conducted once every year. It is prepared and conducted by the training committees.

Surgical Logbook and DOPS (Skills Parameter) Submission of the logbook for surgical rotation for 1st and 2nd year residents is sufficient to obtain a “clear pass,” with “borderline fail” for submission of incomplete logbook and “clear fail” for not submitting a logbook. Any resident beyond their 2nd year should at least submit 4 DOPS per year and a surgical logbook appropriate to their level of training (please refer to Appendix, Table 1). This is an ongoing assessment; the final mark will be given to the trainee at the end of each rotation during the end of rotation face-to-face evaluation. By the end of the academic year, the trainee should have 4 independent DOPS evaluations (one every three months) The average calculated yields 50% in addition to 50% for the logbook.

Forms Trainees and evaluators should use the One45 system and the SCFHS approved forms to

document DOPS and Logbook. Please refer to Appendix 3, 4, and 5. We encourage all trainees to keep a summary of their annual surgical procedures using the

table attached in Appendix 2. The marks for all parameters will be graded according to the SCFHS guidelines: The marking of each continuous assessment tool is based on the guidelines outlined in the

SCFHS executive policy of continuous assessment. A graded scoring system will be applied for each assessment tool (clear pass, borderline pass, clear fail, borderline fail). Trainees should satisfactorily pass each tool. Comprehensive assessment can be applied for borderline failure: refer to the policy on the SCFHS website.

Continuous holistic appraisals and assessments

Mid-rotation assessments and feedback Before completing the first half of any rotation, the trainer/mentor should meet one-to-one at least once with his/her trainee especially if there are any concerns that may yield an undesirable ITER or DOPS. This would be a form of a non-creditable formative evaluation that serves as a constructive feedback for the trainee, the minutes of such meetings should be documented confidentially. Tools such as MiniCEX and others may be used.

Resident portfolio This contains everything the resident has done over his/her period of training, including and not limited to courses, workshops, community work, elective rotations attended, publications, research work, recommendation letters by key figures, and so on.



Summative Assessment These examinations are a responsibility of the Examination committee of the Saudi Commission for Health Specialties. This committee is independent of the Scientific Council of Neurosurgery training program. The Saudi Board has 2 examinations: A. Part 1 neurosurgical principles examination B. Final neurosurgery examination:

1. Final written examination 2. Final Objective Structured Clinical Examination (OSCE)

A. Part 1 Examination The Part 1 Examination of the Saudi Board shall cover applied basic health sciences related to the specialty. This examination is not applicable to other postgraduate training programs such as diplomas and fellowships.

Requirements to take the examination are as follows: 1. Completion of at least 9 months’ training in any of the Saudi Board certificate programs. 2. Valid registration in any of the Commission postgraduate programs. 3. Any other conditions approved by the Council of Education and Training. 4. Completion of the examination registration process within the specified period.

General Provisions 1. The trainee may not be promoted from junior to senior level (as determined by the relevant

Scientific Council) unless he/she passes the Part 1 Examination of the Saudi Board. 2. Exemption from the examination due to the completion of any other previous postgraduate

studies/examinations has to be approved by the Central Training Committee. 3. The Part 1 Saudi Board examination will be held once each year on a date published on

the Commission website. 4. Candidates are allowed a limited number of attempts to pass the Part 1 Saudi Board

examination, before being dismissed from the program (refer to SCFHS assessment executive policy).

5. For further and updated details regarding exam policy and regulations please refer to general bylaw and executive policy of assessment (available on SCFHS website).

Examination Format 1. The Part 1 examination of the Saudi Board certificate shall consist of one paper with 120-

150 multiple-choice questions (single best answer out of 4 options). Ten unscored items can be added for pretesting purposes.

2. If any other assessment format is used, the Central Assessment Committee must agree to its implementation and changes will be announced.



Suggested References 1. Schwartz’s Principles of Surgery textbook (Basic Principles of Surgery section) 2. Schwartz’s principles of surgery: ABSITE and board review 3. Rush University Medical Center Review of Surgery 4. Handbook of Neurosurgery 8th Edition by Mark S. Greenberg. Anatomy, Physiology, and

General Neurosurgery sections 5. Youmans Neurological Surgery textbook (Basic Science and General Neurosurgery

sections) 6. Comprehensive Neurosurgery Board Review by Jonathan Citow (Anatomy, Physiology,

and Critical Care sections) Note: This list is intended for use as a study aid only. SCFHS does not intend the list to imply endorsement of these specific references, nor are the exam questions necessarily taken solely from these sources.

Blueprint Outlines The content of the following table is for demonstration only, please refer to the most updated version published on SCFHS website.

Domains Sections % Diagnosis

and Basic Knowledge

Investigation Treatment Health Care

Promotion and professionalism

Total

Principles of Surgery

50% 50%

Fluids, Electrolytes, and Acid-Base Balance

(10%) 4% 3% 3% -

Shock and Haemostasis

(10%) 4% 2% 4% -

Surgical Infections and Antibiotics

(10%) 4% 2% 4% -

Perioperative Management and Surgical Critical Care

(10%) 3% 3% 4% -

Wounds and Wound Healing

(10%) 6% 1% 3% -

Basic Principles of Neuroscience

20% 20%

Neuro-anatomy (5%) 4% 1% - - Neurophysiology (5%) 3% 2% - -



Neurological examination skills

(5%) 5% - - -

Neurochemistry and pharmacology

(5%) 2% 1% 2% -

Basic Principles of Neurosurgery

20% 20%

Raised ICP, Cerebral Edema, and Brain Herniation

(10%) 4% 2% 4% -

Hydrocephalus and Basic Neurosurgical approaches

(5%) 3% 1% 1% -

Neuotrauma (5%) 3% 1% 1% -

Research and Ethics

10% - - - 10% 10%

Total 100% 100%


Example Questions for K2 Question 1 An otherwise healthy 31-year-old male is involved in a motor vehicle accident. When he presents to ER, a dilated right pupil was identified. He was obeying commands and moving all limbs with a Glasgow Coma Scale score of 15 points. CT brain scan revealed a fracture at the right frontal base extending to the orbital apex. Which of the following is the most appropriate explanation for his dilated pupil? A. Anterior transtentorial herniation B. Right optic nerve injury C. Horner syndrome D. Large right temporal extradural hematoma



Question 2

A 21-year-old male came to the clinic with a visual field chart showing left upper quadrantanopia after neurosurgical intervention to treat epilepsy. MRI of brain is shown. Which of the following is the pathomechanism of his visual field defect? A. Meyer’s loop injury B. Lateral geniculate body injury C. Optic tract injury D. Optic nerve injury

Example Questions for K1 Question 3 A 24-year-old male presents with right/left dissociation, impaired calculation function, finger agnosia, and agraphia. He has right-sided hemiparesis, however, he failed to appreciate his weakness. Which of the following describes his neurological dysfunction? A. Ideational apraxia B. Dejerine-Roussy syndrome C. Akinetic mutism D. Gerstmann’s syndrome



Question 4 A 24-year-old man sustains a head trauma and is found to have an ecchymosis behind the ear that is indicative of which of the following? A. Frontal bone fracture B. Parietal bone fracture C. Skull base fracture D. Orbital bone fracture

B. Final neurosurgery examination

Objectives 1. Determine whether the trainee has sufficient competency related to the required specialty. 2. Determine the eligibility for entering the final clinical examination.

General Provisions 1. Trainees will be required to pass the final written exam in order to be eligible to sit for the

final OSCE exam. 2. The final written examination for Saudi Board certificates will be held once each year. 3. The final written examination may not be repeated. 4. Examination dates shall be provided by the Specialty Examination Committee in

accordance with the approved annual schedule submitted by the Executive Assessment Administration.

5. The candidate remains eligible for the final written examination for a period not longer than 3 years after completion of training provided that he/she presents evidence of continuing clinical practice.

6. For further and updated details regarding exam policy and regulations (e.g. eligibility to sit for exam, number of attempts, etc.) please refer to general bylaw and executive policy of assessment (available on the SCFHS website).

Examination Format A Saudi Board final specialty written examination shall consist of 2 papers each with 100 SBA MCQs. Ten unscored items can be added for pretesting purposes.

Passing Score As these regulations are subject to change, updated details regarding exam policy, regulations, and passing score are available in the general bylaw and executive policy of assessment (available on the SCFHS website).

Suggested References 1. Youman’s Neurological Surgery latest edition 2. Schmidek and Sweet: Operative Neurosurgical Techniques 3. Handbook of Neurosurgery by Mark Greenberg 4. Neuropathology: A Reference Text of CNS Pathology by David Ellison et al.



5. The Human Nervous System by John Kiernan 6. WHO Classification of Tumours of the Central Nervous System from The International

Agency for Research on Cancer 7. Rhoton’s Cranial Anatomy and Surgical Approaches by Albert Rhoton Note: This list is intended for use as a study aid only. SCFHS does not intend the list to imply endorsement of these specific references, nor are the exam questions necessarily taken solely from these sources.

Blueprint Outlines The content of the following table is for demonstration only; please refer to the most up-to-date version published on the SCFHS website.

Section % Clinical and Operative Neurosurgery

Neurovascular 10% Neuro-oncology 10% Cranial Trauma 5% Pediatric Neurosurgery 10% Spine 10% Infection 5% Functional Neurosurgery 5% Peripheral Nerve 5% General Neurosurgical Principles/Neurosurgical Approaches/Adjuvant Therapies

5%

Basic Neurosciences and Practice-related topics Neuro-Anatomy/Neurosurgical Anatomy 10% Neuropathology and Molecular Biology/Neuroradiology and Diagnostic Approaches

10%

Pathophysiology/Neurophysiology/Neurology 5% Neurocritical and General Care/Pharmacology/Neuro- Anesthesia

5%

Research, Ethics, and Professionalism and Patient Safety 5% Total 100%




Example Questions Examples of K2 Questions

A 21-year-old man sustained a cervical spine injury after a fall. His Glasgow Coma Score is 15 (see report).

Blood pressure 100/55 mmhg Heart Rate 86 beats per minute

CT of spine: Showed a transverse fracture line that extends through the body to C2 below the base of the odontoid process. CT of cervical spine is shown (see images). Which of the following represent the classification of this fracture? A. Type I, Odontoid fracture B. Type II, Odontoid fracture C. Type III, Odontoid fracture D. Type II, Hangman’s fracture



Examples of K1 Questions An 18-year-old male is brought into the emergency department after a motor vehicle accident. On examination, he opens his eyes to painful stimulation, makes incomprehensible sounds, and withdraws his extremities to painful stimulation. What is the patient’s Glasgow Coma Scale score? A. 5 B. 6 C. 7 D. 8

Final Objective Structured Clinical Examination (OSCE)

Exam Format 1- The neurosurgery final clinical examination shall consist of 12 graded stations each with

15-minute encounters. 2- The 12 stations consist of 6 Objective Structured Clinical Exam (OSCE) stations with 1

examiner each and 6 Structured Oral Exam (SOE) stations with 2 examiners each. 3- All stations shall be designed to assess integrated clinical encounters. 4- SOE stations are designed with preset questions and ideal answers. 5- Each OSCE station is assessed with a predetermined performance checklist. A scoring

rubric for post encounter questions is also set in advance. 6- As these regulations are subject to change, updated details regarding exam policy and

regulations are available in the general bylaw and executive policy of examination (available on the SCFHS website).

Final Clinical Exam Blueprint Outlines The content of the following table is for demonstration only, please refer to the most updated version published on SCFHS website.



Numbers represent the distribution of clinical assessment scores out of 10 for each station. Cases can differ up to +/-2 Each station includes either OSCE or SOE cases. A single case or multiple cases will be used for each station.

Definitions

Dimensions of care Focus of care for the patient, family, community, and/or population

Clinical assessment The process of initial clinical evaluations that include relevant focused history taking and clinical examination.

Diagnosis and

investigations

Appropriate use of different diagnostic methods and investigations. This dimension includes but is not limited to urgent, emergent, and life-threatening conditions, new conditions, and exacerbation of underlying conditions.

Treatment The process of medical and surgical treatment of acute and chronic neurosurgical conditions.

Surgical treatment Neurosurgical interventions that include but are not limited to surgical approaches, techniques, technology, and interventional procedures.

Overall management

Perioperative patient management in acute and chronic conditions and postoperative care that includes is but not limited to post-surgical complications management, disease prevention, ethics, professionalism, and research.


SECTION 6: CERTIFICATION OF TRAINING COMPLETION In order to be eligible to sit for final specialty examinations, each trainee is required to obtain a “Certification of Training-Completion.” Based on the training bylaws and executive policy (please refer to www.scfhs.org) trainees will be granted “Certification of Training-Completion” once the following criteria are fulfilled: a. Successful completion of all training rotations b. Completion of training requirements as outlined by the scientific council of specialty c. Clearance from SCFHS training affairs that ensures compliance with tuitions payment and

completion of universal topics A “Certification of Training-Completion” will be issued and approved by the local supervisory committee or its equivalent according to SCFHS policies. As these regulations are subject to change, updated details regarding exam policy and regulations are available in the general bylaw and executive policy (available on the SCFHS website).

Appendix

Appendix 1. Procedures List According to this table the minimum number of cases expected per year is as follows (these numbers may vary by +/-10% due to the different rotations performed by the trainee each year): R1 Level: 100 cases/year R2 Level: 110 cases/year R3 Level: 120 cases/year R4 Level: 140 cases/year R5 Level: 150 cases/year R6 Level: 100 cases/year Key O: Observation AS: Assist only PS: Perform under supervision PI: Perform independently (not step-by-step supervised) An empty slot means PI. A number in parentheses is the minimum number to be performed per year of training (these numbers may vary by +/-10% due to the different rotations performed by the trainee each year).

SECTION 6: CERTIFICATION OF TRAINING COMPLETION


CSF pressure release and diversion procedures

RI R2 R3 R4 R5 R6

Lumbar puncture PS (3) PI (3) Ventricular drain and intracranial monitor insertion

PS (4) PS (4) PI (4)

Ventriculoperitoneal shunt insertion

AS (2) AS (2) PS (2) PS (4) PI (4)

Ventriculoperitoneal shunt correction

AS (2) AS (2) PS (2) PS (4) PI (4)

Ommaya reservoir insertion O (1) O (1) AS (1) PS (2) PI (2) Endoscopic third ventriculostomy

O (1) O (1) O (1) AS (2) PS (2) PI (2)

Endoscopic fenestration of loculated hydrocephalus

O (0) O (1) O (1) AS (1) PS (1) PI (2)

CSF leak repair O (2) O (2) AS (2) AS (2) PS (2) PI (2) Head trauma Burr holes for chronic subdural evacuation

AS (2) PS (2) PI (2) PI (4) PI (4)

Hemicraniectomy and bilateral craniotomy for intracranial pressure

O (2) AS (2) PS (2) PI (4) PI (4)

Evacuation of acute epidural and subdural hematomas

O (2) AS (2) PS (2) PI (4) PI (4)

Elevation of Depressed skull fractures with or without dural tear

O (2) AS (2) PS (2) PI (4) PI (4)

Cranioplasty O (2) AS (2) PS (2) PI (4) PI (4) Evacuation of intra-parenchymal hemorrhage

O (2) AS (2) AS (2) PS (4) PI (4) PI (2)

Spinal surgery Laminectomy for cauda equina decompression

O (1) AS (1) AS (1) PS (1) PI (2) PI (2)

Anterior cervical discectomy and fusion

O (1) AS (1) AS (1) AS (1) PS (2) PI (2)

Application of spine traction O (1) AS (2) AS (2) AS (2) PS (2) PI (2) Thoracic disc interventions O (1) AS (1) AS (1) AS (1) PS (2) PS (2) Lumbar and lumbosacral microdiscectomy

O (2) AS (3) AS (4) PS (4) PS (4) PI (4)

Lumbosacral instrumentation O (2) AS (3) AS (4) PS (4) PI (4) PI (4) Laminectomy for stenosis of any vertebrae

AS (2) AS (2) PS (2) PS (2) PI (2) PI (2)

C1-C2 surgery O (0) AS (1) AS (1) PS (1) PS (1) PS (2) Neuro-oncology Operation of neuronavigation systems

AS (2) AS (4) PS (4) PI (4) PI (4)

Resection of cortical metastasis

O (2) AS (2) AS (2) PS (2) PS (2) PI (2)



Resection of convexity meningiomas

O (2) AS (2) AS (2) PS (2) PS (2) PI (2)

Resection of parasagittal meningiomas

O (2) AS (2) AS (2) PS (2) PS (2) PI (2)

Resection of skull base meningiomas

O (2) AS (2) AS (2) AS (2) PS (2) PS (2)

Resection of low-grade gliomas (non-eloquent cortex)

O (2) AS (2) AS (2) PS (2) PS (2) PI (2)

Resection of low-grade gliomas (eloquent cortex)

O (2) AS (2) AS (2) AS (2) PS (2) PS (2)

Resection of high-grade gliomas (non-eloquent cortex)

O (2) AS (2) AS (2) PS (2) PS (2) PI (2)

Resection of high-grade gliomas (eloquent cortex)

O (2) AS (2) AS (2) AS (2) PS (2) PS (2)

Stereotactic brain lesion biopsy (with neuronavigation or a stereotactic frame)

O (2) AS (2) AS (2) PS (2) PI (2) PI (2)

Craniopharyngioma (open) O (1) AS (1) AS (1) AS (1) PS (2) PS (2) Craniotomy for sellar or suprasellar tumors

O (1) AS (1) AS (1) AS (1) PS (2) PS (2)

Transsphenoidal surgery for simple adenoma

O (2) AS (2) AS (2) PS (2) PS (2) PI (2)

Suboccipital craniotomy for tumors

O (3) AS (3) AS (3) PS (3) PS (3) PI (3)

Other complex skull base tumors

O (1) AS (1) AS (1) AS (1) AS (1) PS (1)

Placement of stereotactic frames for radiosurgery and other indications

O (1) AS (1) AS (1) AS (1) AS (1) PS (1)

Extended endoscopic skull base approach

O (1) AS (1) AS (1) PS (1) PS (2) PS (2)

Pediatric and congenital condition surgery Closure of myelomeningoceles

O (2) AS (2) AS (2) PS (3) PS (3) PI (3)

Closure of encephaloceles O (1) AS (1) AS (1) PS (2) PS (2) PI (2) Closure of spinal lipomas O (1) AS (1) AS (1) PS (1) PS (1) PI (2) Spinal cord untethering O (2) AS (2) AS (2) PS (3) PS (3) PI (3) Correction of diastematomyelia

O (1) AS (1) AS (1) PS (1) PS (1) PI (1)

Removing pediatric infratentorial brain tumors

O (2) AS (2) AS (2) PS (3) PS (3) PI (3)

Removing pediatric supratentorial brain tumors

O (2) AS (2) AS (2) PS (3) PS (3) PI (3)



Functional neurosurgery and procedures for epilepsy and pain Temporal lobectomy for epilepsy

O (1) AS (1) AS (1) PS (1) PS (2) PI (2)

Selective amygdalohippocampectomy

O (1) O (1) O (1) PS (1) PS (1) PS (1)

Other epilepsy procedures such as callosotomy and/or hemispherectomy

O (1) O (1) O (1) PS (1) PS (1) PS (1)

Brain mapping O (1) O (1) O (1) PS (1) PS (1) PS (1) Deep brain stimulation for Parkinson’s disease

O (1) O (1) O (1) PS (1) PS (1) PS (1)

Deep brain stimulation for other functional indications

O (1) O (1) O (1) PS (1) PS (1) PS (1)

Vagus nerve stimulator insertion

O (1) AS (1) AS (1) PS (1) PS (2) PI (2)

Baclofen and morphine pump insertion and revision

O (1) AS (1) AS (1) PS (1) PS (2) PI (2)

Spinal cord stimulator insertion

O (1) AS (1) AS (1) PS (1) PS (2) PS (2)

Microvascular decompression for trigeminal neuralgia and hemi-facial spasm

O (1) AS (1) AS (1) PS (2) PS (2) PI (2)

Chiari decompression with or without C1 or C2 laminectomy, duroplasty, or tonsillar herniation

AS (1) AS (1) AS (2) PS (2) PS (2) PI (2)

Peripheral nerve surgery Entrapment neuropathies AS (2) AS (2) AS (2) PS (2) PI (2) PI (2) Resection of peripheral nerve tumors

O (1) O (1) O (1) PS (1) PS (1) PS (1)

Nerve suture O (1) O (1) O (1) PS (1) PS (1) PS (1) Sural nerve harvesting O (2) AS (2) AS (2) PS (2) PI (2) PI (2) Neurovascular surgery Craniotomy for Sp. Mart. grade I, II arteriovenous malformations

O (1) AS (1) AS (1) PS (1) PS (2) PI (2)

Craniotomy for complex arteriovenous malformations

O (1) O (1) O (1) AS (1) AS (1) PS (1)

Sylvian fissure dissection O (1) AS (1) AS (1) PS (2) PS (2) PI (2) Pterional craniotomy approach

O (3) AS (3) AS (3) PS (3) PI (4) PI (4)

Extended Pterional craniotomy

O (3) AS (3) AS (3) AS (3) Ps (4) PS (4)

Resection of surface cavernomas

O (1) AS (1) AS (1) PS (2) PI (2) PI (2)

Clipping of simple aneurysm O (1) AS (2) AS (3) PS (4) PS (4) PI (2) Clipping of complex aneurysm

O (0) O (1) AS (1) AS (1) PS (2) PS (2)



Appendix 2. Annual Summary of Procedures Form Name: SCFHS Number: Period: ( / / ) to ( / / ) Institution(s)

Institution From To Instructors Number of cases

1. 2. 3. 4.

Procedure type Number

Minor Procedures Major Procedures Total Procedures

Specialty Number of cases

Trauma and General Cranial Oncology Spine Cranial Vascular Pediatric Neurosurgery Functional Neurosurgery – movement disorders Functional Neurosurgery – epilepsy surgery Functional Neurosurgery – pain Skull base – Open Skull base – Neuro-endoscopic Peripheral Nerve Surgery Minor Procedures (external ventricular drains, ICP monitors, bedside shunt externalization, etc.)

Sub-specialty ( ) Other Total

Candidate attended a sufficient amount of cases during rotation to fulfill his/her training needs for that level: Yes ( ) No ( ) If not, why? Personal log-book was submitted and discussed at the end of rotation: Yes ( ) No ( ) Total grade for log-book (please check one):



Clear fail (<50%) Border line fail

(50-59.4%) Border line pass

(60-69.4) Clear pass (≥70%)

Comments: ……………………………………………………………………………………………… Signature of faculty: Signature of trainee: Date: Date:



Appendix 3. In-Training Evaluation Report (ITER)





Appendix 4. Direct Observation of Procedural Skills (DOPS Assessment)





Appendix 5. Mini-Clinical Evaluation Exercise (MiniCEX)





Appendix 6. List of topics for Self-directed Learning

Part 1: Basic Science 1. NEUROANATOMY

1.1. Embryology 1.1.1. Cranium

1.1.1.1. Cerebrum 1.1.1.2. Cerebellum 1.1.1.3. Brainstem 1.1.1.4. Basal ganglia 1.1.1.5. Thalamus 1.1.1.6. Cranial nerves 1.1.1.7. Ventricles 1.1.1.8. Skull and fontanelles

1.1.2. Spine 1.1.2.1. Spinal cord 1.1.2.2. Conus medullaris 1.1.2.3. Cauda equina 1.1.2.4. Bony spine

1.1.3. Peripheral nervous system (PNS) 1.1.4. Autonomic nervous systems 1.1.5. Fetal cerebral circulation

1.2. Histology 1.2.1. Neurons

1.2.1.1. Types 1.2.1.2. Microanatomy

1.2.1.2.1. Cell body 1.2.1.2.2. Dendritic process 1.2.1.2.3. Axonal process

1.2.2. Microglial elements 1.2.2.1. Astrocytes 1.2.2.2. Oligodendrocytes 1.2.2.3. Microglia 1.2.2.4. Ependyma 1.2.2.5. Choroid epithelium

1.3. Vascular Anatomy 1.3.1. Carotid and vertebral arteries

1.3.1.1. Course 1.3.1.2. Branches 1.3.1.3. Target structures

1.3.2. Blood supply to the spinal cord and spine 1.3.2.1. Spinal and radicular arteries 1.3.2.2. Watershed strokes

1.3.3. Venous drainage of 1.3.3.1. Cerebrum 1.3.3.2. Cerebellum 1.3.3.3. Spinal cord 1.3.3.4. Spine



1.4. Osteology

1.4.1. Skull 1.4.1.1. Bones 1.4.1.2. Foramina and their contents

1.4.2. Scalp 1.4.2.1. Layers 1.4.2.2. Blood supply 1.4.2.3. Innervation

1.4.3. Spine 1.4.3.1. Atlas and axis vertebrae 1.4.3.2. Subaxial cervical vertebrae 1.4.3.3. Thoracic vertebrae 1.4.3.4. Lumbar vertebrae 1.4.3.5. Sacrum and coccyx 1.4.3.6. Intervertebral disc complex

1.5. Myology 1.5.1. Gross

1.5.1.1. Skull-attacked muscles 1.5.1.2. Spinal muscles 1.5.1.3. Facial muscles 1.5.1.4. Abdominal muscles

1.5.2. Microscopic 1.5.2.1. Motor unit 1.5.2.2. Motor end plate 1.5.2.3. Striated and smooth muscles

1.6. Ventricles 1.6.1. Compartments 1.6.2. Boundaries 1.6.3. Fourth ventricle

1.6.3.1. External topography 1.6.3.2. Anatomical landmarks

1.7. Meninges and CSF 1.7.1. Dura mater

1.7.1.1. Falx cerebri 1.7.1.2. Tentorium 1.7.1.3. Incisura 1.7.1.4. Blood supply

1.7.2. Pia mater 1.7.3. Arachnoid mater

1.7.3.1. Major cisterns 1.7.4. CSF

1.7.4.1. Chemical content 1.7.4.2. Functions 1.7.4.3. Production 1.7.4.4. Circulation and flow 1.7.4.5. Reabsorption

1.7.5. Blood-brain barrier 1.7.5.1. Structure 1.7.5.2. Functions 1.7.5.3. Circumventricular organs



1.8. Central nervous system (CNS)

1.8.1. Topographical anatomy 1.8.1.1. Cerebrum 1.8.1.2. Cerebellum 1.8.1.3. Brainstem 1.8.1.4. Spinal cord

1.8.2. Cerebral cortex 1.8.2.1. Cortical layers 1.8.2.2. Sensory areas 1.8.2.3. Motor areas 1.8.2.4. Prefrontal cortex 1.8.2.5. Fiber tracts 1.8.2.6. Primary visual cortex

1.8.3. Temporal lobe 1.8.3.1. Rhinencephalon 1.8.3.2. Olfactory pathways 1.8.3.3. Anterior commissure 1.8.3.4. Hippocampus 1.8.3.5. Amygdala 1.8.3.6. Limbic system

1.8.4. Corpus striatum 1.8.4.1. Striatum 1.8.4.2. Globus pallidus 1.8.4.3. Caudate nucleus 1.8.4.4. Claustrum 1.8.4.5. Subthalamic region 1.8.4.6. Afferent and efferent connections

1.8.5. Hypothalamus and pituitary gland 1.8.5.1. Hypothalamic cytoarchitecture 1.8.5.2. Hypothalamic connections 1.8.5.3. Supraoptic nuclei and tracts 1.8.5.4. Hypophysial portal system 1.8.5.5. Pituitary stalk 1.8.5.6. Anterior lobe 1.8.5.7. Posterior lobe 1.8.5.8. Hormonally active cells

1.8.6. Diencephalon 1.8.6.1. Midbrain-diencephalon junction 1.8.6.2. Caudal diencephalon 1.8.6.3. Epithalamus 1.8.6.4. Thalamus (including nuclei) 1.8.6.5. Thalamic radiations 1.8.6.6. Internal capsule 1.8.6.7. Visual pathways

1.8.7. Cerebellum 1.8.7.1. Cerebellar organization 1.8.7.2. Deep cerebellar nuclei 1.8.7.3. Cerebellar connections 1.8.7.4. Cerebellar peduncles



1.8.8. Mesencephalon

1.8.8.1. Tectum 1.8.8.1.1. Superior colliculus 1.8.8.1.2. Inferior colliculus

1.8.8.2. Pretectal region 1.8.8.3. Posterior commissure 1.8.8.4. Mesencephalic nuclei 1.8.8.5. Tegmentum 1.8.8.6. Midbrain reticular formation 1.8.8.7. Substantia nigra 1.8.8.8. Crus cerebri 1.8.8.9. Ascending and descending tracts

1.8.9. Pons and medulla 1.8.9.1. Olivary nucleus 1.8.9.2. Medullary reticular formation 1.8.9.3. Pontine cranial nerves 1.8.9.4. Cranial nerves of the medulla 1.8.9.5. Ascending and descending tracts

1.8.10. Cranial nerves 1.8.10.1. Nuclei locations and connections 1.8.10.2. Courses from nuclei to end organs 1.8.10.3. Blood supply 1.8.10.4. Posterior fossa 1.8.10.5. Gacial, vestibular, and cochlear nerves and the internal auditory

canal 1.8.10.6. Mass lesions syndromes affecting cranial nerves in:

1.8.10.6.1. Suprasellar cistern 1.8.10.6.2. Jugular foramen 1.8.10.6.3. Internal auditory canal 1.8.10.6.4. Incisura tentorii

1.9. Spinal cord 1.9.1. Rexed laminae 1.9.2. Somatic and visceral efferent neurons 1.9.3. Posterior horn neurons 1.9.4. Ascending and descending tracts 1.9.5. Upper and lower motoneurons 1.9.6. Somatotopic organization 1.9.7. Boundaries of the spinal neural foramina

1.10. Autonomic nervous system 1.10.1. Pre- and postganglionic neurons 1.10.2. Visceral afferent fibers 1.10.3. Structure of the autonomic ganglia 1.10.4. Central autonomic pathways 1.10.5. Sympathetic functions 1.10.6. Parasympathetic functions



1.11. PNS

1.11.1. Structure 1.11.1.1. Nerve roots 1.11.1.2. Myelinated nerves 1.11.1.3. Unmyelinated nerves 1.11.1.4. Schwann cells

1.11.2. Plexi 1.11.2.1. Cervical plexus 1.11.2.2. Brachial plexus 1.11.2.3. Lumbosacral plexus

1.11.3. Upper extremity 1.11.3.1. Axillary nerve 1.11.3.2. Suprascapular nerve 1.11.3.3. Median nerve 1.11.3.4. Ulnar nerve 1.11.3.5. Radial nerve 1.11.3.6. Long thoracic nerve 1.11.3.7. Musculocutaneous nerve

1.11.4. Lower extremity 1.11.4.1. Lateral femoral nerve 1.11.4.2. Femoral nerve 1.11.4.3. Obturator nerve 1.11.4.4. Sciatic nerve 1.11.4.5. Saphenous nerve 1.11.4.6. Peroneal nerve 1.11.4.7. Tibial nerve

2. NEUROPHYSIOLOGY

2.1. Synaptic transmission 2.1.1. Types 2.1.2. Neurotransmitter release 2.1.3. Neuromuscular transmission 2.1.4. Chemical messengers 2.1.5. Directly gated receptors 2.1.6. Second messenger-linked receptors

2.2. Sensory systems 2.2.1. Sensory receptor physiology 2.2.2. Coding of modality-specific sensation 2.2.3. Pain and analgesia 2.2.4. Cortical integration of sensory perception 2.2.5. Thalamus 2.2.6. Visual system

2.2.6.1. Retinal processing 2.2.6.2. Central visual processing 2.2.6.3. Visual cortex columnar units 2.2.6.4. Geniculate nucleus processing 2.2.6.5. Visual motion and form perception



2.3. Motor system

2.3.1. Muscle contraction mechanisms 2.3.2. Muscle receptors and spinal reflexes 2.3.3. Positional spinal reflexes 2.3.4. Brainstem locomotor reflexes 2.3.5. Vestibular nucleus control of movement and posture 2.3.6. Red nucleus control of movement 2.3.7. Cortical control of movement 2.3.8. Cerebellar control of movement

2.3.8.1. Cerebellar regional and cellular organization 2.3.8.2. Cerebellar functional divisions 2.3.8.3. Cerebellar role in planning movement

2.3.9. Basal ganglia pathways and circuits 2.4. Physiological basis of arousal and emotion

2.4.1. Noradrenergic systems 2.4.2. Limbic system 2.4.3. Memory 2.4.4. Sleeping and sleep states 2.4.5. Reticular activating system

2.5. Higher cortical functions 2.5.1. Anatomy of language 2.5.2. Association cortex

3. FLUID and ELECTROLYTES

3.1. Intracellular and extracellular fluids 3.1.1. Sodium and water distribution and metabolism 3.1.2. Clinical assessment of water and sodium balance 3.1.3. Osmolality

3.2. Management of pathologic conditions 3.2.1. Diabetes insipidus 3.2.2. Syndrome of inappropriate antidiuretic hormone secretion 3.2.3. Cerebral salt wasting

3.3. Clinical implications and treatment of excesses and deficiencies 3.3.1. Calcium 3.3.2. Phosphorous 3.3.3. Magnesium

3.4. Neurosurgical diseases and nutritional deficiencies 3.4.1. Metabolic and nutritional requirements of trauma patients 3.4.2. Swallowing disorders

4. INFECTIONS

4.1. Antimicrobials 4.1.1. Classification 4.1.2. Indications in CNS infections 4.1.3. Potential complications 4.1.4. Traversing the blood-brain barrier



4.2. Corticosteroids: advantages and disadvantages in CNS infections

4.2.1. The mechanism of function of steroids 4.2.2. The blood brain barrier and steroid effect 4.2.3. Potential disadvantage of steroids in infection

4.3. Cranial infections 4.3.1. Meningitis 4.3.2. Tuberculosis 4.3.3. Abscess 4.3.4. Fungi and parasites 4.3.5. Postoperative infections 4.3.6. Dural space infections 4.3.7. Pituitary abscess 4.3.8. Encephalitis 4.3.9. Neurosyphilis 4.3.10. Human immunodeficiency virus

4.4. Spinal infections 4.4.1. Osteomyelitis 4.4.2. Pott’s disease 4.4.3. Spinal epidural abscess 4.4.4. Fungi and parasites

4.5. Managing non-CNS infections in neurosurgical patients 4.5.1. Respiratory infections 4.5.2. Urinary tract infections 4.5.3. Wound infections

4.6. Prion diseases 4.6.1. Clinical evaluation 4.6.2. Prevention

4.7. Fever 4.7.1. Workup for a febrile patient 4.7.2. Postoperative fever etiologies 4.7.3. Diagnosis and management of sepsis 4.7.4. Prophylactic antibiotics

Part 2: General Knowledge 5. NEUROPATHOLOGY

5.1. General 5.1.1. Surgical specimen examination techniques

5.1.1.1. CNS samples 5.1.1.2. PNS samples 5.1.1.3. Skeletal muscle samples 5.1.1.4. Pineal and pituitary samples

5.1.2. Stains 5.1.2.1. Chromatic stains 5.1.2.2. Histochemical stains 5.1.2.3. Immunohistochemical stains

5.1.3. CSF morphological examinations



5.2. Congenital and prenatal disorders

5.2.1. Encephalocele 5.2.2. Myelomeningocele and meningocele 5.2.3. Diastematomyelia and diplomyelia 5.2.4. Syringomyelia and syringobulbia 5.2.5. Chiari malformations 5.2.6. Dandy-Walker malformation 5.2.7. Arachnoid cysts 5.2.8. Porencephaly 5.2.9. Aqueductal stenosis 5.2.10. Subependymal germinal matrix hemorrhages 5.2.11. Posthemorrhagic hydrocephalus 5.2.12. Periventricular leukomalacia

5.3. Trauma 5.3.1. Skull fractures 5.3.2. Gunshot wounds to the skull and brain 5.3.3. Epidural hematomas 5.3.4. Acute and chronic subdural hematomas 5.3.5. Recent and remote cerebral contusions 5.3.6. Intracerebral hemorrhages 5.3.7. Diffuse axonal injuries 5.3.8. Traumatic cranial nerve injuries 5.3.9. Spinal cord injuries 5.3.10. Cerebral herniation syndromes 5.3.11. Fat embolization 5.3.12. Trauma in infancy

5.4. Infectious diseases 5.4.1. Epidural abscess 5.4.2. Subdural abscess 5.4.3. Meningitis 5.4.4. Brain abscesses 5.4.5. Tuberculomas 5.4.6. Sarcoidosis 5.4.7. Cryptococcosis 5.4.8. Mucormycosis 5.4.9. Toxoplasmosis 5.4.10. Cysticercosis 5.4.11. Encephalitis 5.4.12. Human immunodeficiency virus 5.4.13. Cytomegalovirus

5.5. Vascular pathologies 5.5.1. Acute and subacute infarcts 5.5.2. Embolic infarcts 5.5.3. Vasculitis

5.5.3.1. Temporal arteritis 5.5.3.2. Primary CNS vasculitis 5.5.3.3. Granulomatous angiitis 5.5.3.4. Wegener's granulomatosis



5.5.4. Intracerebral hemorrhage

5.5.4.1. Hypertensive hemorrhage 5.5.4.2. Lobar hemorrhage 5.5.4.3. Amyloid angiopathy

5.5.5. Malformations 5.5.5.1. Arteriovenous malformations 5.5.5.2. Cavernous angiomas 5.5.5.3. Venous angiomas 5.5.5.4. Capillary telangiectasias

5.5.6. Aneurysms 5.5.6.1. Saccular aneurysms 5.5.6.2. Mycotic aneurysms 5.5.6.3. Giant aneurysms 5.5.6.4. Traumatic and dissecting aneurysms

5.5.7. Spinal cord 5.5.7.1. Vascular malformations 5.5.7.2. Spinal cord infarcts

5.6. Neoplasms 5.6.1. Gliomas

5.6.1.1. Astrocytomas 5.6.1.1.1. Diffuse fibrillary astrocytomas 5.6.1.1.2. Gemistocytic astrocytomas 5.6.1.1.3. Anaplastic astrocytomas 5.6.1.1.4. Pilocytic astrocytomas 5.6.1.1.5. Cerebellar astrocytomas 5.6.1.1.6. Diencephalic astrocytomas 5.6.1.1.7. Dorsal exophytic pontine astrocytomas 5.6.1.1.8. Pilocytic astrocytomas 5.6.1.1.9. Subependymal giant cell astrocytomas 5.6.1.1.10. Pleomorphic xanthoastrocytomas

5.6.1.2. Oligodendrogliomas 5.6.1.2.1.1. Pure oligodendrogliomas 5.6.1.2.1.2. Anaplastic oligodendrogliomas 5.6.1.2.1.3. Mixed oligodendrogliomas

5.6.1.3. Glioblastomas 5.6.1.3.1.1. Giant cell glioblastomas 5.6.1.3.1.2. Gliosarcomas 5.6.1.3.1.3. Gliomatosis cerebri

5.6.1.4. Ependymomas 5.6.1.4.1.1. Cellular ependymomas 5.6.1.4.1.2. Papillary ependymomas 5.6.1.4.1.3. Clear cell ependymomas 5.6.1.4.1.4. Tanycytic ependymomas 5.6.1.4.1.5. Myxopapillary ependymomas 5.6.1.4.1.6. Subependymomas

5.6.1.5. Neuronal and mixed gliomas 5.6.1.5.1. Gangliocytomas 5.6.1.5.2. Gangliogliomas 5.6.1.5.3. Dysembryoplastic neuroepithelial tumors 5.6.1.5.4. Central neurocytomas



5.6.2. Choroid plexus tumors

5.6.2.1. Papillomas 5.6.2.2. Carcinomas

5.6.3. Embryonal tumors 5.6.3.1. Medulloblastomas 5.6.3.2. Atypical teratoid/rhabdoid tumor 5.6.3.3. Primitive neuroectodermal tumor

5.6.4. Meningiomas 5.6.4.1. Meningothelial meningiomas 5.6.4.2. Fibrous meningiomas 5.6.4.3. Transitional meningiomas 5.6.4.4. Psammomatous meningiomas 5.6.4.5. Angiomatous meningiomas 5.6.4.6. Papillary meningiomas 5.6.4.7. Atypical meningiomas 5.6.4.8. Anaplastic meningiomas 5.6.4.9. Hemangiopericytomas

5.6.5. Pineal and pituitary neoplasms 5.6.5.1. Pineocytomas 5.6.5.2. Pineoblastomas 5.6.5.3. Pituitary adenomas 5.6.5.4. Craniopharyngiomas 5.6.5.5. Rathke pouch cysts 5.6.5.6. Lymphocytic hypophysitis 5.6.5.7. Pituitary apoplexy 5.6.5.8. Empty sella syndrome

5.6.6. Germ cell tumors 5.6.6.1. Germinomas 5.6.6.2. Teratomas 5.6.6.3. Embryonal carcinomas 5.6.6.4. Yolk sac tumors 5.6.6.5. Choriocarcinomas 5.6.6.6. Mixed germ cell tumors

5.6.7. Other neoplasms 5.6.7.1. Colloid cysts 5.6.7.2. Hemangioblastomas 5.6.7.3. Lipomas 5.6.7.4. Primary CNS lymphomas 5.6.7.5. Metastatic carcinomas 5.6.7.6. Leptomeningeal carcinomatosis 5.6.7.7. Schwannomas

5.6.8. Tumor syndromes 5.6.8.1. Neurofibromatosis type 1 5.6.8.2. Neurofibromatosis type 2 5.6.8.3. von Hippel-Lindau syndrome 5.6.8.4. Tuberous sclerosis 5.6.8.5. Cowden syndrome 5.6.8.6. Turcot syndrome



5.7. PNS pathologies

5.7.1. Neuropathies 5.7.9.1.1. Traumatic neuropathies 5.7.9.1.2. Compressive neuropathies 5.7.9.1.3. Metabolic neuropathies

5.7.2. Leprosy 5.7.3. Charcot-Marie-Tooth disease 5.7.4. Guillain-Barre syndrome 5.7.5. Sympathetic dystrophy 5.7.6. Tumors

5.7.9.6.1. Peripheral schwannoma 5.7.9.6.2. Neurofibromas 5.7.9.6.3. Malignant peripheral nerve tumors 5.7.9.6.4. Spinal root and peripheral nerve root cysts

5.8. Skull pathologies 5.8.1. Dermoids and epidermoids 5.8.2. Hemangiomas 5.8.3. Osteomas 5.8.4. Skull chordomas 5.8.5. Eosinophilic granulomas 5.8.6. Paget’s disease 5.8.7. Osteosarcomas

5.9. Spinal pathologies 5.9.1. Herniated intervertebral discs 5.9.2. Tumoral calcinosis 5.9.3. Hemangiomas 5.9.4. Spinal chordomas 5.9.5. Metastatic carcinomas 5.9.6. Plasmacytomas 5.9.7. Primary bone tumors 5.9.8. Spinal osteomyelitis

5.10. Eye and orbit pathologies 5.10.1. Retinoblastomas 5.10.2. Ocular melanomas 5.10.3. Optic nerve gliomas 5.10.4. Optic nerve meningiomas 5.10.5. Orbital lymphomas and pseudotumors 5.10.6. Orbital metastases

6. NEURORADIOLOGY

6.1. General neuroradiology 6.1.1. Radiological safety 6.1.2. Intravenous contrast agents

6.1.2.1. Agent types 6.1.2.2. Potential complications

6.2. Skull X-ray 6.2.1. Anatomical structure identification

6.2.1.1. Anteroposterior view 6.2.1.2. Lateral view 6.2.1.3. Towne view



6.2.2. Traumatic injury identification

6.2.2.1. Linear fractures 6.2.2.2. Decompressed fractures 6.2.2.3. Pneumocephalus 6.2.2.4. Foreign bodies

6.3. Computed tomography scan 6.3.1. Anatomical structure identification 6.3.2. Traumatic injury identification

6.3.2.1. (see 6.2.2.1-4.) 6.3.2.2. Intracranial hematomas

6.3.2.2.1. Epidural hematomas 6.3.2.2.2. Acute and chronic subdural hematomas 6.3.2.2.3. Intraparenchymal hematomas 6.3.2.2.4. Intraventricular hematomas 6.3.2.2.5. Cerebral contusions

6.3.2.4. Subarachnoid hemorrhages 6.3.3. Pathologic condition identification

6.3.3.1. Ischemic infarctions 6.3.3.2. Venous infarctions 6.3.3.3. Hydrocephalus 6.3.3.4. Cysts 6.3.3.5. Tumors 6.3.3.6. Cerebral edema 6.3.3.7. Infections 6.3.3.8. Congenital abnormalities

6.4. Magnetic resonance imaging (MRI) 6.4.1. MRI concepts 6.4.2. MRI sequences 6.4.3. Anatomical structure identification 6.4.4. Traumatic injury identification

6.4.4.1. Pneumocephalus 6.4.4.2. Intracranial hematomas

6.4.4.2.1. (see 6.3.2.2.1-5.) 6.4.4.2.2. Diffuse axonal injuries

6.4.5. Pathologic condition identification 6.4.5.1. (see 6.3.3.1-8.) 6.4.5.2. Vascular occlusions

6.5. Spinal radiology 6.5.1. Anatomical structure identification 6.5.2. Radiographic diagnoses

6.5.2.1. Platybasia 6.5.2.2. Cranial settling

6.5.3. Traumatic injury identification 6.5.3.1. Craniovertebral junction 6.5.3.2. Occipital condyle fractures 6.5.3.3. Atlanto-occipital dislocations 6.5.3.4. Jefferson fractures 6.5.3.5. Posterior atlas fractures 6.5.3.6. Dens fractures



6.5.3.7. Axis body fractures 6.5.3.8. Hangman’s fractures 6.5.3.9. Atlas and axis facet fractures 6.5.3.10. Atlantoaxial rotatory dislocations

7. NEUROLOGY

7.1. Neurophysiology 7.1.1. Normal and abnormal electroencephalogram waveforms 7.1.2. Sensory evoked potential testing 7.1.3. Visual evoked potential testing 7.1.4. Motor evoked potential testing 7.1.5. Nerve conduction velocity testing 7.1.6. Electromyographic testing

7.2. Altered consciousness levels 7.2.1. Delirium 7.2.2. Dementia 7.2.3. Coma 7.2.4. Syncope

7.3. Cerebrovascular neurology 7.3.1. Transient ischemic attacks 7.3.2. Cerebral infarctions 7.3.3. Venous infarctions 7.3.4. Pediatric strokes 7.3.5. Cerebral vasculitis 7.3.6. Brainstem ischemic syndromes 7.3.7. Telangiectasia

7.4. Headaches 7.4.1. Migraines 7.4.2. Non-migrainous headaches

7.5. Epilepsy 7.5.1. Pathophysiology 7.5.2. Clinical presentation 7.5.3. Diagnosis 7.5.4. Treatment 7.5.5. Status epilepticus and its treatment

7.6. Pediatric neurology 7.6.1. Agenesis of the corpus callosum 7.6.2. Anencephaly 7.6.3. Microencephaly 7.6.4. Megalencephaly 7.6.5. Major neurocutaneous disorders

7.7. Neuropathies 7.7.1. Major inherited neuropathies 7.7.2. Guillain-Barre syndrome (GBS) 7.7.3. Non-GBS neuropathies



7.8. Ataxias

7.8.1. Major hereditary ataxias 7.8.1.1. Friedreich ataxias 7.8.1.2. Levy-Roussy syndrome 7.8.1.3. Hereditary cerebellar ataxias

7.8.2. Major non-inherited ataxias 7.8.2.1. Acute cerebellar ataxias in children 7.8.2.2. Ataxia-telangiectasia 7.8.2.3. Marinesco-Sjögren syndrome 7.8.2.4. Ramsay-Hunt syndrome 7.8.2.5. Joseph’s disease

7.9. Degenerative disorders 7.9.1. Alzheimer's disease 7.9.2. Pick’s disease 7.9.3. Diffuse Lewy body disease 7.9.4. Paraneoplastic degenerative diseases 7.9.5. Amyotrophic lateral sclerosis

7.10. Movement disorders 7.10.1. Chorea

7.10.1.1. Huntington’s disease 7.10.1.2. Syndenham chorea 7.10.1.3. Senile chorea

7.10.2. Hemiballismus 7.10.3. Major and focal dystonias 7.10.4. Parkinson’s disease 7.10.5. Tourette’s syndrome 7.10.6. Benign essential tremors 7.10.7. Progressive supranuclear palsy 7.10.8. Tardive dyskinesia

7.11. Spinal cord disorders 7.11.1. Spinal muscular atrophies

7.11.1.1. Wernig-Hoffmann disease 7.11.1.2. Kugelberg-Welander syndrome 7.11.1.3. Benign focal amyotrophy

7.11.2. Poliomyelitis 7.11.3. Neuromuscular junction disorders

7.11.3.1. Myasthenia gravis 7.11.3.2. Lambert-Eaton syndrome

7.11.4. Botulism 7.11.5. Muscular dystrophies

7.11.5.1. Duchenne muscular dystrophy 7.11.5.2. Myotonic dystrophy 7.11.5.3. Congenital dystrophy

7.11.6. Periodic paralysis syndromes 7.11.6.1. Familial periodic paralysis 7.11.6.2. Hypokalemic periodic paralysis 7.11.6.3. Hyperkalemic periodic paralysis

7.12. Demyelinating disease 7.12.1. Multiple sclerosis 7.12.2. Devic’s disease



7.12.3. Inflammatory demyelinating disease 7.12.4. Leukodystrophies

7.12.4.1. Central pontine myelinolysis 7.12.4.2. Tabes dorsalis 7.12.4.3. Subacute combined degeneration

7.13. Miscellaneous disorders 7.13.1. Pseudotumor cerebri 7.13.2. Normal pressure hydrocephalus 7.13.3. Disorders with neurological manifestations

7.13.3.1. Altitude sickness 7.13.3.2. Decompression sickness 7.13.3.3. Malignant hyperthermia

7.13.4. Neurological aspects of pregnancy 8. CRITICAL CARE MEDICINE

8.1. Indications for critical care admission 8.1.1. Adult indications 8.1.2. Pediatric indications

8.2. Managing general medical issues in neurosurgical patients 8.2.1. Universal precautions 8.2.2. Preventing gastrointestinal hemorrhage 8.2.3. Preventing venous thrombosis and pulmonary embolism 8.2.4. Physical therapy to maintain strength and joint range 8.2.5. Skin and eye care 8.2.6. Workup and treatment of sepsis

8.3. Common critical care medications 8.3.1. Vasoactive drugs 8.3.2. Inotropic drugs 8.3.3. Bronchodilators 8.3.4. Diuretics 8.3.5. Antiarrhythmics 8.3.6. Antihypertensives 8.3.7. Antimicrobials 8.3.8. Anticonvulsants

8.4. Drugs that affect neurologic examinations 8.4.1. Sedatives 8.4.2. Paralytics 8.4.3. Analgesics

8.5. Pulmonary care 8.5.1. Indications for intubation

8.5.1.1. Loss of patent airway 8.5.1.2. Respiratory insufficiency

8.5.2. Inability to protect airway 8.5.3. Measured pulmonary functions

8.5.3.1. Rate 8.5.3.2. Minute ventilation 8.5.3.3. Spontaneous tidal volume 8.5.3.4. Forced vital capacity 8.5.3.5. Functional residual capacity 8.5.3.6. Maximum ventilatory volume



8.5.4. Ventilator modes and settings

8.5.4.1. Pressure vs. volume ventilation 8.5.4.2. Continuous positive airway pressure 8.5.4.3. Intermittent positive airway pressure 8.5.4.4. Pressure support 8.5.4.5. Intermittent mandatory ventilation 8.5.4.6. Positive end expiratory pressure 8.5.4.7. Tidal volume

8.5.5. Indications for tapering ventilatory support 8.6. Indications for monitoring devices

8.6.1. Arterial catheters 8.6.2. Central venous catheters 8.6.3. Swan-Ganz catheters 8.6.4. Pulse oximeters 8.6.5. Electrocardiographic monitoring 8.6.6. End-tidal CO2 monitors

8.7. Endocrine disorders 8.7.1. Hypo/hyperthyroidism 8.7.2. Hypo/hyperparathyroidism 8.7.3. Adrenal cortical excess and deficiency 8.7.4. Diabetes mellitus 8.7.5. Diabetes insipidus

8.8. Acid-base balance 8.8.1. Metabolic acidosis and alkalosis 8.8.2. Respiratory acidosis and alkalosis

8.9. Medical and legal definitions of brain death 8.10. Moral and ethical issues pertaining to neurosurgical critical care

8.10.1. Patient or family requests to withhold or withdraw treatment 8.10.2. Organ donation

8.11. Critical care procedures 8.11.1. Endotracheal intubation 8.11.2. Nasogastric intubation 8.11.3. Bladder catheterization 8.11.4. Arterial line insertion 8.11.5. Central venous catheterization

8.12. Neurocritical care 8.12.1. Nutritional management 8.12.2. Critical management of spinal cord injuries 8.12.3. Pathophysiology and critical treatment of cerebral vasospasms 8.12.4. Diagnosis and treatment of cerebral ischemias 8.12.5. Care of birth-related intracranial hemorrhage and injuries to spinal cord and

brachial plexus



9. GENERAL SURGERY

9.1. Perioperative care 9.2. Sterile techniques 9.3. Wound healing and management 9.4. Foundational surgical skills

9.4.1. Applications of bipolar and unipolar cauterization 9.4.2. Basic surgical instruments

9.4.2.1. Scalpels 9.4.2.2. Retractors 9.4.2.3. Suction devices 9.4.2.4. Drills 9.4.2.5. Scissors 9.4.2.6. Drains

9.4.3. Suture materials and stitching techniques

Part 3: Neurosurgical Knowledge 10. CEREBROVASCULAR SURGERY

10.1. Vessel occlusion syndromes 10.1.1. Internal carotid artery 10.1.2. Middle cerebral artery 10.1.3. Anterior cerebral artery 10.1.4. Recurrent artery of Heubner 10.1.5. Anterior choroidal artery 10.1.6. Vertebral artery 10.1.7. Posterior inferior cerebellar artery 10.1.8. Lower and upper basilar trunk

10.2. Cerebrovascular physiology 10.2.1. Cerebral blood flow 10.2.2. Cerebral autoregulation 10.2.3. Ischemic thresholds 10.2.4. Intracranial pressure 10.2.5. Cerebral perfusion pressure

10.3. Hemorrhages 10.3.1. Aneurysmal diseases 10.3.2. Vascular malformations 10.3.3. Hypertension 10.3.4. Vasculopathies 10.3.5. Degenerative diseases 10.3.6. Arterial infarctions 10.3.7. Venous infarctions 10.3.8. Moyamoya disease

10.4. Vascular imaging 10.4.1. Ultrasound 10.4.2. Magnetic resonance angiography 10.4.3. Computed tomography angiography 10.4.4. Digital subtraction angiography

10.5. Extracranial carotid artery diseases 10.5.1. Clinical features and pathophysiology 10.5.2. Diagnostic modalities



10.5.3. Surgical and non-surgical management 10.5.4. Surgical anatomy 10.5.5. Exposing cervical carotid arteries

10.6. Operations 10.6.1. Surgery for aneurysms at various locations 10.6.2. Surgery for arteriovenous malformations 10.6.3. Routine and complex twist drill or burr-hole procedures for draining the

ventricular system or intracranial hematomas 10.6.4. Microsurgical techniques in the laboratory setting 10.6.5. Pterional craniotomy for intracranial vascular pathologies 10.6.6. Vascular disease surgeries

10.6.6.1. Intra-operative anesthesia 10.6.6.2. Proximal and distal control 10.6.6.3. Temporary arterial occlusion 10.6.6.4. Brain protective strategies

10.6.7. Exposure and treatment of intraspinal vascular lesions 11. NEUROSURGICAL ONCOLOGY

11.1. General considerations 11.1.1. Brain tumor epidemiology 11.1.2. Radiologic features of CNS tumors 11.1.3. Basic principles of cranial surgery for brain tumors 11.1.4. Basic principles of skull base surgery 11.1.5. Avoiding complications from brain tumor surgeries 11.1.6. Navigating brain tumors 11.1.7. Endoscopic approaches for brain tumors 11.1.8. Intraoperative MRI

11.2. Gliomas 11.2.1. Proliferation markers 11.2.2. Glial tumor growth factors 11.2.4. Low-grade gliomas 11.2.5. Malignant gliomas 11.2.3. Invasive malignant glioma 11.2.6. Primitive neuroectodermal tumors 11.2.7. Pineal tumors 11.2.8. Medulloblastomas 11.2.9. Ependymomas 11.2.10. Hemangioblastomas

11.3. Extra-axial tumors 11.3.1. Meningiomas 11.3.2. Hemangiopericytomas 11.3.3. Vestibular schwannomas 11.3.4. Ventricular tumors

11.4. Skull base tumors 11.4.1. Pituitary tumors 11.4.2. Craniopharyngiomas 11.4.3. Epidermoid, dermoid, and neurenteric cysts 11.4.4. Chordomas and chondrosarcomas 11.4.5. Glomus tumors 11.4.6. Trigeminal schwannomas



11.5. Other tumors

11.5.1. Osseous tumors 11.5.2. Orbital tumors 11.5.3. Skull and scalp tumors 11.5.4. Metastatic tumors 11.5.5. Primary CNS lymphomas

11.6. Operations 11.6.1. Patient positions for craniotomies 11.6.2. Opening and closing craniotomies 11.6.3. Assessing the need for pre-, intra-, and postoperative monitoring 11.6.4. Neoplasm resection

11.6.4.1. Intra-axial neoplasms 11.6.4.1.1 Supratentorial neoplasms 11.6.4.1.2. Infratentorial neoplasms

11.6.4.1. Extra-axial neoplasms 11.6.5. Pituitary lesion resection 11.6.6. Performing or assisting skull base procedures 11.6.7. Managing postoperative complications

11.6.7.1. Brain edema 11.6.7.2. Meningitis 11.6.7.3. Cranial flap infections 11.6.7.4. Postoperative seizures 11.6.7.4. Other complications

11.7. Chemotherapy 11.7.1. Classes of chemotherapy related to neuro-oncology 11.7.2. Mechanism of action of chemotherapy agents 11.7.3. Common therapeutic régimes 11.7.4. Common complications

11.8. Radiation therapy 11.8.1. Linear accelerator radiosurgery 11.8.2. Gamma knife radiosurgery 11.8.3. Image-guided robotic radiosurgery: the CyberKnife 11.8.4. Radiosurgery for intracranial vascular malformations 11.8.5. Radiosurgery for functional disorders

12. TRAUMA

12.1. Polytraumas 12.1.1. Obtaining Advanced Trauma Life Support certificates 12.1.2. Assessment 12.1.3. Resuscitation 12.1.4. Management

12.2. Cranial hemorrhages 12.2.1. Pathophysiology 12.2.2. Types

12.2.2.1. Epidural hemorrhages 12.2.2.2. Subdural hemorrhages 12.2.2.3. Intracerebral hemorrhages 12.2.2.4. Intraventricular hemorrhages

12.2.3. Clinical features 12.2.4. Management



12.3. Skull fractures

12.3.1. Types 12.3.1.1. Linear fractures 12.3.1.2. Depressed fractures 12.3.1.3. Compound fractures 12.3.1.4. Basal fractures

12.3.2. Management 12.3.3. Traumatic skull base fractures with CSF leakage

12.4. Intracranial hypertension 12.4.1. Pathophysiology 12.4.2. Monro-Kellie doctrine 12.4.3. Management 12.4.4. Inserting intracranial pressure monitoring devices

12.5. Managing infections associated with open CNS injuries 12.6. Operations

12.6.1. Twist-drill or burr-hole drainage for subdural fluid collection 12.6.2. Patient surgical positions and initial emergency procedures 12.6.3. Surgical procedures in uncomplicated cases

12.6.3.1. Craniotomies for subdural and/or epidural hematomas 12.6.3.2. Craniotomies for penetrating head injuries 12.6.3.3. Craniotomies for intracerebral hematomas or contusions 12.6.3.4. Craniotomies for depressed skull fractures 12.6.3.5. Decompressive craniectomies 12.6.3.6. Repairs/canalizations of frontal sinus fractures 12.6.3.7. Craniotomies/craniectomies for posterior fossa epidural, subdural, or

intracerebral hematomas 12.6.3.8. Simple cranioplasties 12.6.3.9. Reconstructing complex cranial defects, with assistance from other

specialties as indicated 12.6.3.10. Reconstructing traumatic skull base defects, with assistance from

other specialties as indicated. 12.6.3.11. Assisting explorations and repairs for peripheral nerve injuries

13. PEDIATRIC NEUROSURGERY

13.1. Congenital/developmental embryonic defects 13.1.1. Incidence, epidemiology, and inheritance patterns 13.1.2. Myelomeningoceles and meningoceles 13.1.3. Encephaloceles 13.1.4. Chiari malformations 13.1.5. Dandy-Walker syndrome 13.1.6. Achondroplasia and other dwarfisms 13.1.7. Occult spinal dysraphism 13.1.8. Split cord anomalies 13.1.9. Tethered spinal cord

13.1.9.1. Fatty filum terminales 13.1.9.2. Meningocele manqué

13.1.10. Craniofacial syndromes 13.1.11. Arachnoid cysts 13.1.12. Phakomatoses



13.2. Hydrocephalus

13.2.1. Etiologies and relative incidences 13.2.2. Infantile posthemorrhagic hydrocephalus 13.2.3. Low-pressure and high-pressure hydrocephalus 13.2.4. Treatment and management options 13.2.5. Shunt types and their pros and cons 13.2.6. Treatment complications 13.2.7. Nonsurgical diseases mistaken for hydrocephalus

13.3. Shunt infections 13.3.1. Presentations 13.3.2. Common pathogens 13.3.3. Risk factors 13.3.4. Treatment plans

13.4. Neoplasias 13.4.1. Common pediatric tumors and their locations 13.4.2. Typical presentations and appropriate evaluations 13.4.3. Tumor malignancy classifications 13.4.4. Surgical vs. nonsurgical therapies and their outcomes 13.4.5. Type-specific tumor complications 13.4.6. Preoperative tumor management

13.5. Cerebrovascular surgeries 13.5.1. Causes of atraumatic intracerebral and subarachnoid hemorrhages 13.5.2. Causes of cerebral infarctions/ischemias 13.5.3. Embryology of pediatric cerebral and spinal vascular anomalies 13.5.4. Common pediatric aneurysm types and their locations 13.5.5. Diagnosing and managing vein of Galen aneurysms 13.5.6. Pathophysiology, treatment, and outcomes of intraventricular neonatal

hemorrhages 13.6. Trauma

13.6.1. Glasgow Coma Scale 13.6.2. Diagnosing non-accidental trauma 13.6.3. Common injuries from birth trauma 13.6.4. Growing skull fractures

13.7. Miscellaneous pediatrics 13.7.1. Diagnosing and managing cerebral palsy 13.7.2. Pediatric spasticity and movement disorders 13.7.3. Craniosynostosis

13.7.3.1. Acquired craniosynostosis 13.7.3.2. Syndromic craniosynostosis 13.7.3.3. Open vs. endoscopic treatments 13.7.3.4. Plagiocephaly

14. SPINE SURGERY

14.1. Biomechanics 14.1.1. Craniocervical junction biomechanics 14.1.2. Cervical biomechanics 14.1.3. Thoracolumbar biomechanics 14.1.4. Lumbar biomechanics 14.1.5. Internal spinal fixator biomechanics



14.2. Spinal pain

14.2.1. Differential diagnosis by location 14.2.1.1. Cervical pain 14.2.1.2. Thoracic pain 14.2.1.3. Lumbar pain

14.2.2. Differential diagnosis by cause 14.2.2.1. Degenerative origin 14.2.2.2. Traumatic origin 14.2.2.3. Metabolic origin

14.2.3. Evaluation 14.2.3.1. History and physical exam 14.2.3.2. Investigations

14.2.3.2.1. Laboratory tests 14.2.3.2.2. Radiological tests

14.2.4. Management 14.2.4.1. Non-surgical management 14.2.4.2. Surgical management

14.3. Degenerative disorders 14.3.1. Clinical disorders

14.3.1.1. Radiculopathy 14.3.1.2. Myelopathy 14.3.1.3. Neurogenic claudication

14.3.2. Indications for cervical and lumbar discectomy 14.3.3. Surgeries for thoracic herniated discs 14.3.4. Cervical rheumatoid arthritis 14.3.5. Cervical spondylotic myelopathy 14.3.6. Posterior longitudinal ligament ossification

14.4. Tumors 14.4.1. Spinal cord tumors

14.4.1.1. Intradural tumors 14.4.1.1.1. Intramedullary tumors 14.4.1.1.2. Extramedullary tumors

14.4.1.3. Extradural tumors 14.4.2. Boney spine tumors

14.4.2.1. Primary tumors 14.4.2.2. Secondary tumors

14.5. Spine infections 14.5.1. Spontaneous infections 14.5.2. Postoperative infections 14.5.3. Tuberculosis 14.5.4. Fungal infections

14.6. Spinal cord trauma 14.6.1. Pathophysiology of spinal cord injury 14.6.2. Grading schemes for spinal cord injury and myelopathy 14.6.3. Initial management of spine and spinal cord injuries

14.6.3.1. Immobilization 14.6.3.2. Traction

14.6.3.2.1. Gardner-Wells tongs 14.6.3.2.2. Halo vest

14.6.3.3. Reduction



14.6.4. Spinal cord injury syndromes

14.6.4.1. Complete transverse injuries 14.6.4.2. Anterior cord injuries 14.6.4.3. Brown-Sequard injuries 14.6.4.4. Central cord injuries 14.6.4.5. Cruciate paralysis 14.6.4.6. Syringomyelia 14.6.4.7. Conus syndrome 14.6.4.8. Sacral sparing

14.6.5. Non-surgical spinal cord syndromes 14.6.5.1. Radiographic identification 14.6.5.2. Medical management

14.6.6. Fractures 14.6.6.1. Injury mechanisms 14.6.6.2. Location categories

14.6.6.2.1. Cervical fracture 14.6.6.2.2. Throacolumbar fractures 14.6.6.2.3. Sacral fractures 14.6.6.2.4. Coccygeal fractures

14.6.6.3. Other fractures 14.6.6.3.1. Pathological fractures 14.6.6.3.2. Osteopathic fractures

14.6.7. Other injuries 14.6.7.1. Subluxations 14.6.7.2. Ligamentous injuries 14.6.7.3. Spinal gunshots and penetrating wounds

14.7. Instability 14.7.1. Punjabi and White definition of spinal instability 14.7.2. Radiographic signs of instability

14.7.2.1. Degenerative instability 14.7.2.2. Neoplastic instability 14.7.2.3. Traumatic instability 14.7.2.4. Congenital instability

14.8. Spinal orthoses 14.8.1. Indications 14.8.2. Relative effectiveness 14.8.3. Degree of segmental and regional immobilization

14.9. Intraoperative spinal cord monitoring 14.9.1. Indications 14.9.2. Physiology 14.9.3. Technical aspects

14.10. Miscellaneous 14.10.1. Cauda equina syndrome 14.10.2. Treating adult tethered cord syndrome and syringomyelia 14.10.3. Management of intra and postoperative CSF leaks 14.10.4. Indications for angiography and endovascular management of spinal

disorders 14.10.5. Bone healing and bone grafting in spinal surgery



14.11. Operations

14.11.1. Cervical operations 14.11.1.1. Anterior and posterior cervical spine approaches

14.11.1.1.1. Herniated cervical discs 14.11.1.1.2. Spondylosis 14.11.1.1.3. Instability

14.11.1.2. Indications for posterior cervical spinal internal fixators 14.11.1.3. Indications and techniques for anterior and posterior cervical

spinal internal fixators 14.11.1.4. Operations for fractures and dislocations affecting the atlas and

axis 14.11.1.5. Anterior and posterior approaches for fractures and dislocations

of the subaxial cervical spine 14.11.2. Thoracolumbar operations

14.11.2.1. Anterior and posterior spinal fixators 14.11.2.1.1. Tumors 14.11.2.1.2. Trauma 14.11.2.1.3. Infection

14.11.2.2. Lumbar fusion indications 14.11.2.2.1. Congenital disorders 14.11.2.2.2. Iatrogenic disorders 14.11.2.2.3. Degenerative disorders

14.11.2.3. Anterior or posterior lumbar interbody fusion and intertransverse fusion for lumbar diseases

14.11.2.4. Internal fixation options for posterior lumbar interbody and intertransverse fusion

15. FUNCTIONAL NEUROSURGERY

15.1. Movement disorders 15.1.1. Anatomy and synaptic connectivity of the basal ganglia 15.1.2. Clinical overview of movement disorders 15.1.3. Pros and cons of ablative procedures 15.1.4. Deep brain stimulation (DBS)

15.1.4.1. Mechanisms 15.1.4.2. Patient selection criteria

15.1.5. Functional imaging of movement disorders 15.1.6. Surgical tremor management 15.1.7. Parkinson’s disease

15.1.7.1. Pallidal interventions 15.1.7.2. DBS for Parkinson’s disease

15.1.7.2.1. Subthalamic DBS 15.1.7.2.2. Subthalamotomy DBS

15.1.8. DBS for dystonia 15.1.9. Psychosurgery

15.1.9.1. Tourette’s syndrome 15.1.9.2. Obsessive-compulsive disorder 15.1.9.3. Major depression

15.1.10. Stereotactic biopsy 15.1.10.1. Frame-based vs frameless biopsies 15.1.10.2. Benefits and limitations of frame-based biopsies



15.1.10.3. Minimizing the risk of intracranial hemorrhage 15.1.10.4. Minimizing the risk of a non-diagnostic stereotactic biopsy 15.1.10.5. Appropriate biopsy trajectories

15.1.10.5.1. Pineal lesions 15.1.10.5.2. Midbrain lesions 15.1.10.5.3. Pontine lesions 15.1.10.5.4. Medullary lesions

15.2. Epilepsy 15.2.1. Cortical malformations 15.2.2. Diagnosis and classification of seizures and epilepsy 15.2.3. Antiepileptic drugs 15.2.4. Neuroradiologic tests for epilepsy surgery 15.2.5. Evaluating patients for epilepsy surgery 15.2.6. Motor, sensory, and language mapping 15.2.7. Surgeries for extratemporal lobe epilepsy 15.2.8. Standard temporal lobectomies 15.2.9. Selective amygdalohippocampectomies 15.2.10. Hemispheric disconnection procedures 15.2.11. Vagus nerve stimulation for intractable epilepsy 15.2.12. Radiosurgery for epilepsy 15.2.13. DBS for epilepsy 15.2.14. Outcomes and complications of epilepsy surgery

15.3. Radiosurgery 15.3.1. Stereotactic radiosurgery 15.3.2. Radiosurgery vs. radiation therapy 15.3.3. Indications 15.3.4. Complications 15.3.5. Advantages and disadvantages of radiosurgery and surgical resection

15.3.5.1. Tumors 15.3.5.2. Vascular malformations

16. PAIN MANAGEMENT

16.1. Anatomy and physiology of pain 16.2. Pharmacologic treatment of pain 16.3. Anesthesia for pain 16.4. Trigeminal neuralgia

16.4.1. Diagnosis and non-surgical treatments 16.4.2. Percutaneous procedures 16.4.3. Stereotactic radiosurgery 16.4.4. Microvascular decompression

16.5. Neurostimulation for pain 16.5.1. Peripheral nerve stimulation 16.5.2. Spinal cord stimulation 16.5.3. Motor cortex stimulation

16.6. Destructive procedures 16.6.1. Diagnosing and managing painful neuromas 16.6.2. Dorsal root entry zone lesions 16.6.3. Percutaneous cordotomy and trigeminal tractotomy-nucleotomy



17. PERIPHERAL NERVE SURGERY

17.1. Anatomy 17.1.1. Major peripheral nerve structural elements

17.1.1.1. Epineurium 17.1.1.2. Perineurium 17.1.1.3. Endoneurium 17.1.1.4. Axon 17.1.1.5. Fascicle 17.1.1.6. Schwann cell 17.1.1.7. Connective tissue 17.1.1.8. Motor end plate 17.1.1.9. Sensory receptor

17.1.2. Blood supply to peripheral nerves 17.1.3. Blood-nerve barrier 17.1.4. Major peripheral nerves

17.1.4.1. Motor innervation 17.1.4.2. Sensory innervation

17.2. Physiology 17.2.1. Fast and slow axonal transport 17.2.2. Action potentials and ion flows 17.2.3. Action potential propagation 17.2.4. Nerve fiber sizes 17.2.5. Functional significance of fiber size

17.3. Peripheral nerve examinations, evaluations, and biopsies 17.3.1. Motor power rating scales 17.3.2. Sensory modalities and their examinations 17.3.3. Tinel’s sign 17.3.4. Symptoms and signs of upper vs. lower motoneuron injuries

17.3.4.1. Anatomical definition 17.3.4.2. Degree of atrophy 17.3.4.3. Distribution of weakness 17.3.4.4. Reflex changes 17.3.4.5. Recovery probabilities

17.3.5. Wallerian degeneration 17.3.6. Nerve regeneration

17.3.6.1. Sprouting 17.3.6.2. Nerve growth factors 17.3.6.3. Growth rates 17.3.6.4. Remyelination

17.3.7. Neuromas 17.3.7.1. Axonal tangle 17.3.7.2. Mechanosensitivity 17.3.7.3. Neuromas-in-continuity

17.4. Electrodiagnostic evaluations 17.4.1. Electromyography 17.4.2. Nerve conduction studies

17.5. Neuropathies 17.5.1. Metabolic neuropathies 17.5.2. Inherited neuropathies



17.6. Horner’s syndrome

17.6.1. Clinical features 17.6.2. Causes 17.6.3. Management

17.7. Entrapments 17.7.1. Distal entrapments

17.7.1.1. Carpal tunnel syndrome 17.7.1.2. Cubital tunnel syndrome 17.7.1.3. Peroneal nerve entrapment 17.7.1.4. Tarsal tunnel syndrome

17.7.2. Pelvic entrapments 17.7.2.1. Piriformis syndrome 17.7.2.2. Obturator internus syndrome 17.7.2.3. Pudendal nerve entrapment

17.7.3. Uncommon entrapments 17.7.3.1. Guyon’s canal syndrome 17.7.3.2. Suprascapular nerve entrapment 17.7.3.3. Posterior interosseous nerve syndrome 17.7.3.4. Anterior interosseous nerve syndrome

17.7.4. Thoracic outlet syndrome 17.8. Injuries

17.8.1. Burn and electrical injury effects on nerves 17.8.2. Management of acute peripheral nerve injuries 17.8.3. Brachial plexus injuries

17.8.3.1. Congenital brachial plexus injuries 17.8.3.2. Early management of brachial plexus injuries 17.8.3.3. Secondary procedures for brachial plexus injuries

17.8.4. Meralgia paresthetica 17.8.5. Timing of peripheral nerve surgery

17.8.5.1. Laceration injuries 17.8.5.2. Blunt injuries 17.8.5.3. Missile injuries 17.8.5.4. Non-surgical iatrogenic injuries 17.8.5.5. Surgical injuries 17.8.5.6. Injection injuries

17.8.6. Adjuvant therapies for nerve injuries 17.8.6.1. Muscle and tendon transfers 17.8.6.2. Prosthesis 17.8.6.3. Joint fusion

17.9. Tumors 17.9.1. Benign peripheral nerve tumors 17.9.2. Surgery for malignant peripheral nerve sheath tumors

17.10. Operative considerations 17.10.1. Nerve repair site tension 17.10.2. Nerve repair techniques

17.10.2.1. Direct coaptation 17.10.2.2. Nerve grafts

17.10.2.2.1. Graft donor nerves 17.10.2.3. Nerve transfers



17.10.2.5. Epineurial repairs 17.10.2.6. Fascicular repairs

17.10.3. Intra-operative nerve evaluations 17.10.3.1. Visual evaluations 17.10.3.2. Palpation 17.10.3.3. Internal neurolysis 17.10.3.4. Nerve conduction studies 17.10.3.5. Biopsies

17.10.4. Carpal tunnel decompression 17.10.4.1. Open decompression 17.10.4.2. Endoscopic decompression

17.10.5. Ulnar nerve decompression 17.10.5.1. In situ decompression 17.10.5.2. Transposition

17.10.5.2.1. Subcutaneous transposition 17.10.5.2.2. Intramuscular transposition 17.10.5.2.3. Submuscular transposition

17.10.5.3. Medial epicondylectomy 17.10.6. Sural nerve biopsy

Documents

Saudi Board of Neurosurgery Curriculum - SCFHS